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A   SYSTEM   OF   GYNECOLOGY 


^^^y^- 


A 


SYSTEM  OF  GYNECOLOGY 


BY   MANY   WRITERS 


EDITED  BY 

THOMAS   CLIFFORD   ALLBUTT 

M.A.,  M.D.,  LL.D.,  F.R.C.P.,  F.B.S.,  F.L.S.,  F.S.A. 

EEGIU8   PROFESSOR   OP   PHYSIC    IN   THE   UNIVERSITY   OF   CAMBRIDGE, 

FELLOW   OF  GONVILLE   AND   CAICS   COLLEGE 

AND 

W.   S.   PLAYFAIR 

M.D.,    LL.D.,    F.R.C.P. 

PROFESSOR   OF   OBSTF.TRIO   MEDICINE   IN    KING'S   COLLEGE,    AlTD 

OBSTETRIC   PHYSICIAN   TO   KLNG'S   COLLEGE   HOSPITAL 


Ncto  Hork 
THE   MACMILLAN   COMPANY 

LONDON:  MACMILLAN  &  CO.,  Ltd. 

1897 

All  rights  reserved 


MS 


Copyright,  1896, 
By  the   MACMILLAN    COMPANY. 


Set  up  and  electrotyped  October,  1896.       Reprinted  October, 
1897. 


Koriuooli  ^rrsss 

J.  S.  Cuihiiig  k  Co.  -  Hurwlck  &  .Smith 
Norwuoil  Mail.  U..S.A. 


PEEFACE 

In  the  earlier  treatises  on  medicine  diseases  of  women  were  included, 
but  were  of  necessity  imperfectly  described. 

Of  late  years  this  department  of  medicine  has  grown  so  largely 
that  the  Editor  of  the  new  System  of  Medicine  found  it  would  be 
better  to  deal  with  it,  as  a  whole,  in  a  volume  especially  devoted  to 
the  subject;  in  the  preparation  of  this  volume  I  have  assisted  him 
as  Joint  Editor. 

The  advances  made  within  the  last  few  years  in  Gynaecology  are 
perhaps  more  remarkable  than  in  any  other  branch  of  medicine. 

The  whole  subject  is  one  of  recent  development.  Even  the 
work  of  its  pioneers  is  within  the  recollection  of  the  older  amongst 
us :  a  treatise  on  gyngecology  written  twenty  years  ago  is  ab- 
solutely useless  as  a  guide  to  the  practice  of  to-day,  and  does  not 
contain  even  a  reference  to  many  of  the  topics  now  known  to  be  of 
primary  importance  in  connection  with  diseases  of  the  reproductive 
organs  in  women;  on  the  other  hand,  many  opinions  and  methods 
of  treatment,  then  largely  taught  and  practised,  have  justly  passed 
into  oblivion. 

Much  of  this  great  progress  is  undoubtedly  on  the  surgical 
aspect  of  the  subject.  The  increasing  frequency  of  abdominal 
sections  has  directed  attention  to  the  diseased  states  thus  revealed, 
and  to  methods  of  treating  them,  previously  quite  unknown. 

Unbalanced  zeal  has  had  its  inevitable  result  of  injudicious 
practice,  which  is  to  be  regretted ;  against  adventure  of  this 
kind    protests    have   been   made    by   the   more    conservative    minded 


SYSTEM   OF  GYNECOLOGY 


members  of  our  profession,  often  justly,  sometimes  unjustly. 
Xor  is  it  in  this  country  alone  that  this  adventurousness  is  seen. 
Any  one  familiar  with  current  gyna?cological  practice,  both  on  the 
Continent  and  in  the  United  States,  must  know  that  the  same  spirit 
is  active  there.  Indeed,  it  is  probable  that  gyusecologists  abroad 
are  apt  to  impute  to  their  British  colleagues  a  backwardness  in 
adopting  methods  of  treatment  largely  practised  by  themselves ; 
many  of  us  think,  too  largely.  Conservatism  of  this  sort  may  have 
its  faults,  but,  on  the  whole,  it  is  not  to  be  regretted,  and  it  is 
surely  better  than  to  err  in  the  opposite  direction. 

It  is  obvious  that  a  collection  of  independent  essays,  written  by 
men  on  topics  Avhicli  they  have  specially  studied,  must  carry  more 
weight,  and  be  more  useful  than  any  work  compiled  by  a  single 
writer.  An  endeavour  has  been  made  to  entrust  the  several  subjects  to 
thoroughly  representative  men;  and  it  is  hoped  that  the  results  of 
their  combined  labours  will  give  an  accurate  exposition  of  gynse- 
cology  as  it  is  taught  and  practised  amongst  us. 

I  am  myself  alone  responsible  for  the  selection  of  the  contributors, 
which  my  co-editor  has  left  to  my  judgment;  but  I  am  not  in  any 
way  responsible  for  the  opinions  they  have  expressed,  —  some  of 
them,  indeed,  I  do  not  share. 

In  a  work  by  various  authors  differences  of  opinion  will 
necessarily  be  found ;  some  condemn  methods  of  practice  which 
others  approve  and  recommend.  This  does  not  appear  to  be 
objectionable  ;  it  is  surely  better  that  in  vexed  and  disputed  ques- 
tions both  sides  should  be  fairly  considered. 


W.  S.  PLAYFAIR. 


CONTENTS 


The  Development  of  Modern  GrxiECOLOGY.     M.  Handfield-Jones   . 
The  Anatomy  of  the  Female  Pelvic  Organs.     D.  Berry  Hart 
Malformations    of    the    Genital    Organs    in    "Woman.     J.  "William  Bal 


lantyne 


Organs.      "W 


Playfair 


Robert   Milne 


The  Etiology  of  the  Diseases   of   the   Female   Genital 

Balls-Headley  ..... 

Diagnosis  in  Gynecology.    Robert  Boxall 
Inflammation  of  the  Uterus.     A.  H.  Freeland  Barbour 
The  Nervous  System  in  Relation  to  Gynecology.     "W.  S. 
Sterility.     Henry  Gervis   ..... 
Gynecological  Therapeutics.     Amand  Routh 
The    Electrical    Treatment    of    Diseases    of    Women. 

Murray  ...... 

Disorders  of  Menstruation.     John  Halliday  Croom    . 

Diseases  of  the  External  Genital  Organs.     "William  J.  Smyly 

Displacements  of  the  Uterus.     Alexander  Russell  Simpson 

Morbid   Conditions    of   the    Female    Genital    Organs   resulting    from 

Parturition.    George  Ernest  Herman 
Extra-uterine  Gestation.     John  Bland  Sutton 
Pelvic  Inflammation.     Charles  James  Cullingworth 
Pelvic  H.ematocele.     "William  Overend  Priestley 
Benign  Growths  of  the  Uterus.    F.  W.  N.  Haultain 
Hysterectomy.     J.  Knowsley  Thornton    . 

vii 


1 
31 

63 

11-2 
151 
187 
220 
231 
240 

300 
339 
372 
393 

425 
451 
485 
524 
561 
611 


SYSTEM   OF  GYNECOLOGY 


Malignant  Diseases  of  the  Uterus.     TV.  J.  Sinclair 

Plastic  Gynjecological  Operations.     Jolin  Phillips 

Diseases  of  the  Fallopian  Tubes.     Alban  Doran 

Diseases  of  the  Ovary.     W.  S.  A.  Griffith 

Ovariotomy.    J.  Greig  Smith  ... 

Chronic  Inversion  of  the  Uterus.     Edward  Malins 

Diseases  of  the  Female  Bladder  and  Urethra.     Henry  Morris 


PAQB 

643 
743 

782 
836 
872 
911 
927 


INDICES 


959 


ILLUSTRATIONS 


FIG. 

1.  Brim  of  Bony  Pelvis       ...... 

2.  Diagram  of  Bony  Pelvis  and  of  Pelvic  Floor  . 

3.  Sagittal  Mesial  Section  of  Female  Pelvic  Floor 

4.  Virgin  External  Genitals  with  the  Labia  Majora  separated  . 

5.  Rectal  and  Vaginal  Mucous  Membrane 

6.  Sphincter  Ani  in  full-time  Foetus  .... 

7.  Axial  Transverse  Section  of  right  half  of  Female  Pelvic  Floor 

8.  Axial  Transverse  Section  of  Female  Pelvic  Floor 

9.  Axial  Coronal  Section  of  right  half  of  Female  Pelvis 

10.  Blood-supply  of  Uterus  ...... 

1 1 .  Lymphatics  of  Uterus     ...... 

12.  Lymphatics  of  Uterus  and  Pelvis  .  . 

13.  Nerve  Diagram    .  . 

14.  Relations  of  Uterus  and  Ovaries  viewed  through  Brim 

15.  Sagittal  Lateral  Section  of  Female  Pelvis 

16.  Uterine  Mucous  Membrane  showing  relation  of  Glands  and  Stroma 

17.  Cervix  and  upper  part  of  Vagina  showing  Rugae 

18.  Seal's  Ovary  showing  Cortical  and  Medullary  Layers 

19.  Sagittal  Lateral  Section  of  Genital  Organs  in  3^  months'  Foetus 

20.  Pelvis  and  Contents  from  above  .... 

21.  Perineal  Region  ....... 

22.  Sacral  Section  of  Pelvic  Floor  ..... 

23.  Diagram  of  Genu-Pectoral  Posture  showing  Vaginal  Distension 

24.  Dissection  from  behind  ...... 

25.  T.  S.  of  Wolffian  Bodies  in  six  weeks'  Foetus  . 

26.  T.  S.  Pelvis,  six  weeks'  Foetus  ..... 


PAGB 

32 

32 
33 
34 
36 
38 
39 
40 
41 
42 
42 
43 
44 
45 
46 
47 
47 
49 
50 
52 
54 
66 
66 
58 
69 
59 


SYSTEM  OF  GYNECOLOGY 


27.  T.  S.  of  six  Tveeks'  Foetus  showing  Genital  Cord 

28.  Section  of  Ovary  and  Wolffian  Body,  Human  Embryo,  third  month 

29.  L.  S.  of  3i^  months'  Fo3tus  to  show  development  of  Hymen  . 

30.  Diagram  of  developing  and  fully  formed  Genital  Tract 

31.  Anterior  View  of  right  Uterine  Appendages   .... 

32.  Congenital  absence  of  outer  two-thirds  of  right  Fallopian  Tube 

33.  Uterus  Didelphys 

34.  Uterus  Bicornis  . 

35.  Uterus  Septus 

36.  Uterus  Unicornis,  posterior  view 

37.  Atresia  Vulvae  Superficialis 

38.  Anus  Vulvalis     . 

39.  Pseudo-Hermaphroditism,  Perineo-Scrotal  Hypospadias 

40.  Female  Generative  Organs  of  Halmaturus       .... 

41.  Two  completely  separated  Uteri  of  many  Rodentia    . 

42.  Single  Uterus   continued  into  two  separate  Cornua  of  the  Insectivora 

Carnivora,  Cetacea,  and  Ungulata        .... 

43.  The  single  Uterus  of  the  Simise  and  Man        .... 

44.  Section  of  a  Catarrhal  Patch  on  the  Vaginal  Aspect  of  the  Cervix  . 

45.  Healing  of  a  Catarrhal  Patch  treated  by  Astringent  or  Antiseptic  Injections 
40,  47.  Schroeder's  operation  for  excision  of  the  Cervical  Mucous  Membrane 

in  Cervical  Catarrh         ....... 

48,  49.  Section  of  Tissue  removed  by  Curette  from  a  case  of  Interstitial 
Endometritis       ...... 

50.  Section  of  the  Glands  from  a  case  of  Glandular  Endometritis 

51.  Section  of  the  Uterine  Tissue  in  a  case  of  Chronic  Metritis 

52.  Leiter's  Coils 

53.  Application  of  Leiter's  Coils 

54.  Bath  Speculum    . 

55.  Syijhon  Douche  . 

56.  Bed  Bath 

57.  Ointment  Carrier  (Matthews  Duncan's) 
68.  Diverging  Speculum  (Neugebaur's) 

59,  Playfair's  Probe 

60.  Uterine  Tenaculum  Forceps  (Sims') 

01.  Intra-Uterine  Canula  (Atthill's)  ;  Platinum  Canula,  with  Stilette 
62.  Uterine  Scarifier  ...... 


PAGE 

60 
60 
61 
62 
70 
71 
75 
76 
78 
79 
92 
94 
104 
114 
114 

114 
114 
196 

201 

202 

208 
208 
214 
267 
258 
258 
259 
260 
263 
263 
264 
264 
265 
266 


ILLUSTRATIONS 


FIG. 

63.  Steriliser  for  Instruments  (Harrison  Cripps') 

64.  Glass  Jar  for  Sponges,  Wool-Pads,  etc, 

65.  Steriliser  for  Ligatures  . 

66.  Catgut  or  Silk  sterilised  in  Alcohol 

67.  Junker's  Inhaler 

68.  Griffin's  Speculum 

69.  Cusco's  Speculum 

70.  Gauge  Applicator  (Whalebone) 

71.  Forceps  to  introduce  Gauge 

72.  Cervical  Speculum  (Bantock's) 

73.  Duckbill  Speculum  (Sims') 

74.  Barnes'  Tent  Introducer 

75.  Chambers'  Tent  Introducing  Forceps 

76.  Uterine  Dilator  (Hegar's  improved) 

77.  Uterine  Dilators  (Hayes') 

78.  Uterine  Dilator  (Matthews  Duncan's) 

79.  Clover's  Crutch  . 

80.  Teale's  Forceps  .  .       ■      , 

81.  Budin's  Tube 

82.  Graily  Hewitt's  Uterine  Tube   . 

83.  Goodell's  two  Parallel-bladed  Dilator 

84.  Uterine  Dilator  (ElHnger's) 

85.  Sims'  Three-bladed  Dilator 

86.  Palmer's  Two-bladed  Dilator     . 

87.  Dilator  (Priestley's) 

88.  Uterine  Dilators  (Reid's) 

89.  Scissors,  Uterine  (Kuchenmeister's) 

90.  Sims'  Metrotome 

91.  Simon's  Uterine  Scoop  . 
02.  Sims'  Pliable  Curette     . 

93.  Double  Uterine  Curette  (Gervis') 

94.  Kecamier's  Curette 

95.  Uterine  Scoop,  or  Spoon  Saw  (Thomas') 

96.  Dredging  Curette  (Bell's) 

97.  Uterine  Flushing  Curette  (Auvard's) 

98.  Routh's  Flushing  Curette 

99.  Vertical  Section  three  months  after  Curcttin 


SYSTEM   OF  GYNECOLOGY 


FIG.  PACK 

100.  Vertical  Section  of  the  Uterine  Mucous  Membrane  fifty-five  days  after 

tlie  application  of  a  Caustic       ......  298 

101.  L^clanche  Cell  .........  oOl 

102.  Carbon  Rheostat  .        .  .  .  .  .  .  .  .30-3 

103.  Edelmann  Galvanometer         .......  304 

104.  Weston  Milliampfere  Meter      .......  305 

105.  Intra-Uterine  Electrode            .......  305 

106.  Apostoli's  Carbon  Electrode    .......  306 

107.  Adjustable  Platinum  Electrode            ......  306 

108.  Electrode  for  Puncture             .......  306 

109.  Vaginal  Electrodes       ........  307 

110.  Portable  Battery  with  Collector  and  Galvanometer             .            .            .  300 

111.  Spamer's  Induction  Coil           .            .            .            .            .'          .            .  310 

112.  Sledge  Induction  Coil  ........  310 

113.  Regulator  Switch  Board  for  Continuous  and  Induced  Currents      .            .  311 

114.  Switch    Board    for   regulating   Lighting    Currents    by    means    of    Re- 

sistances .........  312 

115.  Diagram  of  Switch  Board  for  regulating  Lighting  Currents  by  means  of 

Shunt        .........  313 

116.  Switch  Board  for  Shunt  Regulation    ......  313 

117.  Descent  of  Perineal  Hernia  in  front  of  the  Broad  Ligament           .            .  380 

118.  Reposition  of  the  Retroverted  Uterus  with  the  Sound          .            .            .  418 

119.  Hodge  Pessary  in  the  Vagina  retaining  the  Uterus  zn  st7?t  .            .            .  419 

120.  Profile  on  Section  of  lacerated,  but  healthy,  Cervix  Uteri   .            .            .  427 

121.  Profile  on  Section  of  lacerated  and  inflamed  Cervix  Uteri   .            .            .  427 

122.  Lacerations  of  Cervix  Uteri  and  Vagina        .....  428 

123.  Laceration  of  Vagina  forming  a  "  Pocket  "  .....  430 

124.  Central  Rupture  of  Perineum              ......  4.']4 

125.  Diagram  showing  different  kinds  of  Fistula  .....  ^37 

126.  Annular  sloughing  of  Cervix  Uteri,  upper  surface    ....  438 

127.  Annular  sloughing  of  Cervix  Uteri,  lower  surface    ....  439 

128.  Slough  in  one  mass  of  Cervix  Uteri,  upper  part  of  Vagina,  and  base  of 

Bladder 440 

129.  Dilated  Abdominal  O.stium      .  .  .  .  .  .  .454 

1.'50.  Gravid  Tube      .........  455 

131.  Tubal  Mole  in  Section  .....-.•  4.^ 

l.'}2.  Microscopical  Characters  of  Chorionic  Villi  in  section,  in  Blood-clot         .  457 


ILLUSTRATIONS 


KIG.  PAGE 

133.  Diagram  to  show  the  early  relations  of  the  Amnion  and  Chorion  and  the 

Subchorionic  Chamber  .......  458 

134.  An  early  Tubal  Embryo,  showing  the  Polar  Disposition  of  the  Villi          .  458 

135.  A  Gravid  Tube  with  patent  Ostium    ......  460 

136.  Fallopian  Tube  and  Ovary  ;  Mole  and  Corpus  Luteum  from  a  case  of 

complete  Tubal  Abortion  .  .  .  .  .  .401 

137.  Uterine  Decidua  ;  from  a  case  of  Tubal  Pregnancy  ....  465 

138.  Transverse  Section  of  the  Pelvis  of  a  Woman  with  an   Embryo   and 

Placenta  of  the  fourth  month  of  Gestation  occupying  the  right 

Mesometrium       ........  466 

139.  Sagittal  Section  of  a  Cadaver,  with  a  Mesometrium  Pregnancy  at  Term  .  467 

140.  Tubo-Uterine  Gestation           .......  470 

141.  Injected  Uterus  with  Fibroid  .......  566 

142.  Microscopic  Section  of  soft  Fibromyoma       .....  507 

143.  Microscopic  Section  of  common  Fibromyoma           ....  568 

144.  Section  of  Fibroid  Uterus        .......  569 

145.  Diagram  of  Growth  of  Uterine  Fibroids         .....  570 

146.  Encapsulated  Submucous  Fibroid  becoming  Polypoidal    ■  .  .  .571 

147.  Submucous  Polypus     ........  572 

148.  Uterus,  showing  Subperitoneal  Fibroids        .....  575 

149.  Submucous  Intravaginal  Cervical  Fibroid      .....  582 

150.  Subserous   Cervical   Fibroid,   tilting   Uterus   above  Pubes   and   bulging 

Posterior  Vaginal  Wall  .  .  .  .  .  .  .582 

151.  Advanced  Fibrocystic  Degeneration  of  Stalked  Subperitoneal  Fibroid, 

with  partially  Twisted  Pedicle               .....  587 

152.  CEdematous  Interstitial  Cystic  Fibromyoma             ....  588 

153.  Microphotograph   of   CEdematous   Fibroid,    showing   Endothelial   Lined 

Spaces      .........  589 

154.  Complete  l\upture  of  the  Perineum  and  the  lo^Yer  Portion  of  the  Recto- 

Vaginal  Septum               .......  746 

155.  Relations  of  Levator  Ani  to  the  Rectum  and  Vaginal  Walls  ;   normal 

Condition             ........  746 

156.  Relations  of  Levator  Ani  to  the  Rectum  and  Vaginal  Walls  ;    injured 

Condition             ........  747 

157.  Perineorrhaphy  ;  preliminary  Incisions         .....  749 

158.  Perineorrhaphy  ;  Denudation              ......  749 

159.  Purse-string  Suture       ........  750 


SYSTEM   OF   GYX.-ECOLOGY 


TAGF, 

.  750 

.  750 

.  751 

.  752 

and  Side  View  753 


160.  Perineorrhaph)' ;  Repair  of  the  Recto-Vaginal  Septum 

161.  Section  of  torn  Sphincter         .... 

162.  Perineorrhaphy  ;  Recto- Vaginal  Septum  repaired    . 

163.  „  (Simon-Hegar  Method  of  Suture)  . 

164.  „  ,,  ,,  ,,      2nd  Stage 

165.  ,,              Alexander  Duke's  Method  .....  754 

166.  Surface  View  of  Posterior  Vaginal  Wall  with  Right  and  Left  Lateral  Sulci  755 

167.  ,,  „  „  ,,  ,,      with  both  Lateral  Vaginal  Sulci 

sutured     .........  755 

168.  Elytrorrhaphy  (Sims')  .  .  .  .  .  .  .757 

169.  Anterior  Colporrhaphy  ;;  Denudation  and  first  Layer  of  continuous  Suture 

completed            ........  758 

170.  Anterior   Colporrhaphy  ;    Passage   of   second   continuous   superimposed 

Suture      .........  759 

171.  jVnterior  Colporrhaphy  ;  Passage  of  third  Layer  of  superimposed  Suture  .  759 

172.  Lefort's  Operation        ........  760 

173.  Colpoperineorrhaphy,  first  stage         ......  760 

174.  ,,                ,,               second  stage  ......  761 

175.  „  ,,  third  stage      .  .  ,  .  .  .761 

176.  Stoltz's  Operation  for  Cystocele  .  .  .  .  .  .762 

177.  Urethrocele        .........  762 

178.  Vaginal  Fixation           ........  764 

179.  Emmet's  Scissors  (left  angular)         ......  766 

180.  ,,              ,,         (angular  and  curved)        .....  767 

181.  Operation  for  Subinvolution    .......  767 

182.  Amputation  of  Cervix  ;  Hegar  Method          .....  770 

183.  „  „         Marckwald  Method .  .  .  .  .770 

184.  Vesico- Vaginal  Fistula  Knives  (Sims')          .         '  .            .            .            .  774 

185.  Uterine  Hook  (Emmet's)  for  making  counter  pressure        .            .            .  774 
180.  Wire  Adjuster  .........  774 

187.  Mode  of  freshening  the  Edges  of  a  Fistula  by  "Flap-splitting"    .            .  775 

188.  Mode  of  passing  Sutures  in  Vesico- Vaginal  Fistula              .            .            .  775 

189.  Mode  of  applying  Counter  Pressure  to  the  Point  of  the  Needle  by  means 

of  a  Blunt  Hook  (Emmet's)      .  .  .  .  .  .776 

190.  Method  of  fixing  and  twisting  the  Sutures  (Sims')  ....  777 

191.  Juxta-Cervical  Fistula  (superficial  variety)   .....  779 

192.  Kolpokleisis       .........  781 


ILL  US  TRA  TIONS  xv 


FIG.  PAGE 

193.  Section  of  a  healthy  Tube  from  a  young  Subject      ....  784 

194.  One  of  the  Plicae  in  Fig.  193  as  seen  under  a  1  inch  objective         .  .  785 

195.  Section,  near  the  Ostium,  of  an  inflamed  Tube         ....  786 
190.  Section  of  a  Plica,  showing  the  earlier  Changes  seen  in  Salpingitis            .  787 

197.  Section  showing  the  free  Surface  of  the  Interior  of  a  Tube  which  had  been 

obstructed  and  dilated  for  a  long  period  ....     787 

198.  Section  of  an  inflamed  Tube,  in  its  Middle  Third,  showing  active  Inflam- 

mation     .........  788 

199.  The  free  Surface  of  the  Interior  of  a  suppurating  Tube       .  .  .  789 

200.  Section  of  a  suppurating  Tube,  showing  advanced  Disease  .  .  790 

201.  Ovary  and  Tube,  showing  Obstruction  of  the  Ostium  by  a  Perimetritic 

Band  which  forms  a  Deep  Pouch  .....     792 

202.  Tube  showing  Obstruction  of  the  Ostium  from  inflammatory  Swelling  of 

its  Coats  .........     792 

203.  Tubes  and  Uterus  from  a  Patient  who  died  of  Phthisis  three  years  after 

Incision  of  Peritoneum  infected  with  Tubercle  .  .  .     797 

204.  Cystic  Pibromyoma  of  the  Fimbrise   ......     802 

205.  Microscopical  Section  of  a  Papillomatous  Outgrowth  from  the' Left  Tube  .    804 

206.  Papilloma  of  the  Fallopian  Tube        .  .  .  .  .  .808 

207.  ,,  ,,  ,,     Sections  of  an  outgrowth  under  high  and 

lov,'  Power  ,  .  .         '   .  .  .  .  .809 

208.  Primary  Cancer  of  Fallopian  Tube     ......     814 

209.  ,,  ,,  ,,  ,,      in  Section,  with  Tubule-like  Structure    815 

210.  Dr.  CuUingworth's  case  of  Primary  Cancer  of  the  Tube      .  ,  .     819 

211.  Dr.  Essex  Wynter's  case  of  Cancer  of  the  Tube       ....     822 

212.  Diagram  to  show  placing  of  Table,  Surgeon,  Assistants,  Nurse,  and  In- 

struments in  Ovariotomy  ......     870 

213.  Tait's  Modification  of  Wells'  Catch-Forceps  .  .  .  .877 

214.  Catch-Forceps  (J.  Greig  Smith's  Model)        .  .  .  .  .878 

215.  Blades  of  J.  Greig  Smith's  Forceps     .  .  .  .  .  .878 

216.  J.  Greig  Smith's  Peritoneal  Catch-Forceps    .....    878 

217.  ,,  ,,        Large  Pressure-Forceps       .....    879 

218.  Wells'  Large  Forceps,  bent     .  .  .  .  .  .  .879 

219.  ,,         ,,  ,,  straight  .  .  .  .  .  .879 

220.  ,,        ,,      Pressure-Forceps,  Rectangular  Blades  .  .  .    880 

221.  Thornton's  T-shaped  Pressure-Forceps  .....     880 

222.  Wells'  Clamp-Forceps .881 


xvi 


SYSTEM  OF  GYNECOLOGY 


FIG. 

223.  N61atou's  Cyst-Forceps 

224",  Sydney  Jones'  Cyst-Forceps   . 

225.  J.  Greig  Smith's  Scissors 

226.  „  „        Eeel  Holder  . 

227.  TV  ells'  Large  Cyst- Trocar 

228.  Wells'  Small  Cyst-Trocar  with  Fitch's  Dome 

229.  Tail's  Cyst-Trocar 

230.  Sydney  Jones'  Pedicle  Needle 

231.  Wells'  Pedicle  Needle  . 

232.  J.  Greig  Smith's  Forceps  for  placing  Ligature  on  Pedicle 

233.  Keith's  Glass  Drainage  Tube  . 

234.  Glass  Drainage  Tube    . 

235.  Sponge  Holder  .... 

236.  J.  Greig  Smith's  Suture  Instrument  . 

237.  Tail's  Staffordshire  Knot 

238.  Triple  interlocking  Ligature,  Threads  inserted,  Loops  divided 
2.39.      ,,  ,,  ,,  Threads  interlocked  ready  for  tying 

240.  ,,  ,,  ,,  Threads  tied    . 

241.  Screw  for  aiding  in  the  Delivery  of  Solid  Tumours  . 

242.  Aveling's  Repositor  for  producing  Elastic  Pressure  . 


PAGB 

881 
881 
882 
882 
883 
883 
883 
884 
884 
884 
884 
885 
885 
885 
889 
890 
890 
890 
896 
923 


LIST   OF   AUTHOES 

Ballantyne,  John  Win.,  M.D.,  F.R.C.P.,  F.R.S.  Edin.,  Lecturer  on  Midwifery  and 
Diseases  of  "Women,  Medical  College  for  "Women,  Edinburgh. 

Balls-Headley,  "W.,  M.A.,  M.D.,  F.R.C.P.,  Lecturer  on  Midwifery  and  Diseases  of 
Women,  University  of  Melbourne. 

Barbour,  A.  H.  Freeland,  M.A.,  B.Sc,  M.D.,  F.R.C.P.  Edin.,  Lecturer  on  Mid- 
wifery and  Diseases  of  Women,  Edinburgh  Medical  School. 

Boxall,  Robert,  M.D.,  M.R.C.P.,  Assistant-Obstetric  Physician  and  Lecturer  on 
Practical  Midwifery  and  Gynsecology,  Middlesex  Hospital. 

Groom,  John  Halliday,  M.D.,  F.R.C.P.  Edin.,  Physician  to  the  Royal  Infirmary, 
Edinburgh,  Clinical  Lecturer  on  Diseases  of  Women,  and  Lecturer  on  Mid- 
wifery and  Diseases  of  Women  at  the  Medical  School. 

Cullingworth,  Chas.  James,  M.D.,  D.C.L.,  F.R.C.P.,  Obstetric  Physician  and 
Lecturer  on  Midwifery  and  Diseases  of  Women,  St.  Thomas'  Hospital. 

Doran,  Alban,  F.R.C.S.  Eng.,  Surgeon  to  the  Samaritan  Free  Hospital  for  Women. 

Gervis,  Henry,  M.D.,  F.R.C.P.,  Consulting  Obstetric  Physician  to  St.  Thomas' 

Hospital. 
Griffith,   Walter,  S.A.,  M.D.,  F.R.C.P.,  Assistant-Physician  Accoucheur  to  St. 

Bartholomew's  Hospital. 

Handfield-Jones,  Montague,  M.D.,  Obstetric  Physician  and  Lecturer  on  Midwifery 
and  Diseases  of  Women  to  St.  Mary's  Hospital. 

Hart,  David  Berry,  M.D.,  F.R.C.P.  Edin.,  Lecturer  on  Midwifery  and  Diseases  of 
Women,  Edinburgh  Medical  School. 

Haultain,  F.  W.  N.,  M.D.,  F.R.C.P.  Edin.,  Lecturer  on  Midwifery  and  Diseases 
of  Women,  Edinburgh  Medical  School. 

Herman,  Geo.  Ernest,  M.B.,  F.R.C.P.,  Senior  Obstetric  Physician  and  Lecturer  on 

Midwifery  to  the  London  Hospital. 
Malins,  Edward,  M.D.,  M.R.C.P.,  Obstetric  Physician  to  the  Birmingham  General 

Hospital,  Professor  of  Midwifery  at  Mason  College. 
Morris,  Henry,  M.A.,  M.B.,  F.R.C.S.,  Surgeon  to  the  Middlesex  Hospital. 


SYSTEM   OF  GYNECOLOGY 


Murraj-,  Robt.  Milne,  M.A.,  M.B.,  F.R.C.P.  Edin.,  F.R.S.E.,  Lecturer  on  Mid- 
wifery and  Diseases  of  Women,  Edinburgii  Medical  School. 

Phillips,  John,  M.A.,   M.D.,   F.R.C.P.,   Assistant  Obstetric  Physician  to  King's 
College  Hospital. 

Playfair,  W.  S.,  M.D.,  LL.D.,  F.R.C.P.,  Professor  of  Obstetric  Medicine  in  King's 
College,  and  Obstetric  Physician  to  King's  College  Hospital. 

Priestley,   Sir  AV.   Overend,   M.P.,   M.D.,  LL.D.,  F.R.C.P.,  Consulting  Obstetric 
Physician  to  King's  College  Hospital. 

Routh,  Aniand  J.,  M.D.,  B.S.,  M.R.C.P.,  Obstetric  Physician  to  out-patients  to 
Charing  Cross  Hospital,  Physician  to  Samaritan  Free  Hospital  for  Women. 

Simpson,  Alex.  Russell,  M.D.,  F.R.C.P.  Edin.,  Professor  of  Midwifery,  University 
of  Edinburgh. 

Sinclair,  W.  Japp,  M.A.,  M.D.,  M.R.C.P.,  Professor  of  Obstetrics  and  Gynajcology, 
Owens  College,  Victoria  University. 

Smith,  Jas.  Greig,  M.A.,  M.B.,  F.R.S.  Edin.,  Professor  of  Surgery,  University 
College,  Bristol. 

Smyly,  Wm.  J.,  M.D.,  F.R.C.P.  Ireland,  Master  of  the  Rotunda  Hospital,  Dublin. 

Sutton,  John  Bland,  F.R.C.S.,  Assistant  Surgeon  to  the  Middlesex  Hospital,  Sur- 
geon to  the  Chelsea  Hospital  for  Women. 

Thornton,  J.  Knowsley,  M.B.,  CM.,  Consulting  Surgeon  to  the  Samaritan  Free 
Hospital. 


In  order  to  avoid  frequent  interruption  of  the  text,  the  Editor  has  only  inserted 
the  numbers  indicative  of  items  in  the  lists  of  "  i?e/e?'ences  "  in  eases  of  emphasis, 
where  two  or  more  references  to  one  author  are  in  the  list,  where  an  author  is  quoted 
from  a  work  published  under  another  name,  or  where  an  authoritative  statement  is 
made  without  mention  of  the  author's  name.  In  ordinary  cases  an  author's  name  is 
a  sufficient  indication  of  the  corresponding  item,  in  the  list. 


THE   DEVELOPMENT   OF   MODERN   GYNECOLOGY 

Great  as  the  progress  has  been  during  the  last  fifty  years  in  every 
domain  of  medicine,  in  no  department  has  it  been  so  marked  as  in  that 
which  embraces  the  diseases  peculiar  to  women.  Indeed,  in  tracing  the 
developments  of  modern  gynaecology,  it  is  difficult  for  the  student  of  our 
times  to  estimate  the  value  of  each  claim  to  progress,  and  to  set  a  just 
price  on  each  alleged  advance ;  for  it  must  be  allowed  that  among  many 
brilliant  achievements  many  false  starts  have  been  made,  and  the  boasted 
triumph  of  yesterday  has  been  ranked  among  the  failures  of  to-day. 

Sir  William  Priestley,  in  his  address  before  the  section  of  Obstetric 
^Ledicine  and  Gynaecology,  says :  "  Looking  back  on  forty  years  of 
gynaecological  practice,  I  can  recollect  what  has  been  termed  a  craze 
tor  inflammation  and  ulceration  of  the  os  and  cervix  uteri.  During  its 
]n'evalence,  it  was  said  of  some  devotees  that  every  woman  of  a  house- 
hold was  apt  to  be  regarded  as  suffering  from  these  affections,  and 
locally  treated  accordingly.  Shortly  afterwards  came  a  brief  and  not 
very  creditable  period  when  clitoridectomy  was  strongly  advocated  as  a 
remedy  for  numerous  ills.  This,  fortunately,  had  a  very  limited  currency 
and  "was  speedily  abandoned.  Then  followed  a  time  in  which  displace- 
ment of  the  uterus  held  the  field,  and  every  backache,  every  pelvic  dis- 
comfort, every  general  neurosis,  was  attributed  to  mechanical  causes,  and 
must  needs  be  treated  by  uterine  pessaries.  Again  we  had  an  epoch 
when  oophorectomy  was  not  only  recommended,  and  largely  practised 
as  a  means  of  restraining  haemorrhage  in  bleeding  fibroids,  but  also  as  a 
remedy  for  certain  forms  of  neurosis,  even  when  the  ovaries  were  healthy 
or  not  seriously  diseased.  Ere  long  it  was  discovered  that  removing  the 
ovaries  for  neuroses,  even  if  safely  accomplished  as  far  as  life  was 
concerned,  Avas  freqxiently  followed  by  more  serious  nervous  penalties 
than  those  for  which  it  had  been  used  as  a  remedy;  that,  in  fact, 
it  often  entailed  a  loss  of  mental  equilibriinn,  and  sometimes  ended 
in  insanity.  Close  upon  this,  again,  came  an  ardour  for  stitching  up 
rents  in  the  cervix  uteri  following  child-birth,  rents  which  were  described 
as  producing  many  hitherto  iniknown  evils,  and  frequently  conducing  to 
the  establishment  of  malignant  disease.  Lastly,  we  have  had  what  has 
been  described  as  an  epidemic  of  operations  for  the  excision  of  tlie  utei'ine 

1  B 


SYSTEM   OF  GYNAECOLOGY 


appendages ;  and  even  now,  though  this  operation  has  but  recently  come 
into  vogue,  there  is  a  reaction  against  its  too  frequent  performance,  and 
a  demand  in  its  place  for  more  conservative  methods,  which  shall  leave 
these  parts  of  the  generative  system  a  chance  of  still  performing  their 
important  functions." 

"Whatever  may  have  been  the  mistakes  or  the  delays  in  true  progress, 
it  is,  at  any  rate,  pleasant  to  know  that  the  age  of  mere  speculation  and 
ignorant  mysticism  has  passed ;  and  that  the  accurate  knowledge  and 
fuller  certainties  of  the  present  day  have  been  won  by  anatomical 
and  pathological  research,  and  by  patient  clinical  observation  both  in  the 
sick-room  and  the  operating  theatre. 

It  will  always  be  a  pleasant  task  to  acknowledge  the  deep  debt  of 
gratitude  which  gynaecology  owes  to  Sir  Joseph  Lister ;  for  without  his 
scientific  discoveries  and  brilliant  teaching  the  successes  of  modern 
pelvic  and  abdominal  surgery  could  never  have  been  won. 

The  groundwork  of  all  true  development  in  any  branch  of  medical 
science  must  lie  in  the  establishment  of  an  accurate  knowledge  of 
anatomical  detail,  and  a  correct  appreciation  of  pathological  changes. 
It  may  be  well  to  review  the  advance  of  our  knowledge  in  these  sub- 
jects; and  first  in  anatomy. 

Anatomy.  —  The  bloocl-supjoly  of  the  uterus,  by  the  uterine  and  ovarian 
arteries,  has  been  well  known  and  described  by  anatomists  for  many 
years  past ;  but  the  manner  in  which  the  blood  is  distributed  to  the  organ 
had  been  less  minutely  studied:  until  Sir  John  Williams  wrote  his 
now  classical  paper  "  On  the  Circulation  in  the  Uterus,  with  some  of  its 
Anatomical  and  Pathological  Bearings,"  our  knowledge  of  this  important 
subject  was  extremely  imperfect.  Sir  John  Williams  pointed  out  that 
the  provision  for  the  flow  of  blood  into  and  out  of  the  uterus  is  such, 
that  the  process  could  with  difficulty  be  disturbed  by  mechanical  causes. 
The  entrance  and  the  exit  take  place  at  the  sides  of  the  organ  at 
numerous  points,  and  not  at  its  extremities ;  while  in  the  uterus  the 
direction  of  the  current  is  transverse  to  its  length  and  perpendicular  to 
its  surface :  a  ligature  might  therefore  be  placed  round  the  uterus  at 
any  point  without  affecting  the  circulation  above  and  below.  The  only 
ligature  which  could  materially  interfere  with  the  flow  of  blood  into  the 
uterus,  or  out  of  it,  is  one  surrounding  the  broad  ligaments  (their  Tipper 
))fH'ders  V^eing  included  within  it),  together  with  a  portion  of  the  uterus. 
In  this  case  the  inflows  to  the  jjarts  above  or  within  the  ligature,  and  the 
outflows  from  them,  would  be  diminished  or  stopped.  Conditions  similar 
to  this  are  found  when  the  uterus  foi'ins  a  hernia,  either  in  the  inguinal 
canal  or  in  the  (tanal  or  pouch  of  Douglas.  Whcm  the  fundus  of  the 
uterus  is  found  in  the  pouch  of  Douglas  the  condition  is  spoken  of  as  a 
retroflexion  or  retroversion  ;  but  it  is  really  a  great  deal  more  than  this : 
it  would  be  as  correct  to  speak  of  the  condition  found  when  the  uterus 
is  in  the  inguinal  canal  as  anteflexion  or  anteversion.  liotli  are  true 
lierni.'B,  and  the  symf)toms  are  due  in  great  y)art  to  tlie  constriction  at 
the  neck  of  the  sac — in  j)osterior  h(!rniaby  the  sacro-uterine  ligaments. 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY  3 

There  is  another  condition  which  may  interfere  Avith  the  return  of 
blood  from  the  uterus,  namely,  procidentia.  Here  all  the  veins  of  the 
broad  ligaments  may  be  so  stretched  that  their  channels  may  be 
considerably  diminished,  and  all  the  channels  for  the  return  of  blood 
from  the  uterus  may  be  so  narrowed  that  the  organ  must  consequently 
suffer  from  passive  congestion.  These  two  conditions,  hernise  of  the 
uterus  and  great  procidentia,  appear  to  be  the  only  displacements  of  the 
uterus  which  can  give  rise  to  congestion  of  the  organ. 

To  those  who  remember  the  period  in  the  development  of  gynaecology 
when  uterine  displacements  were  made  to  explain  endless  ills,  it  will  be 
clear  that  the  publication  of  the  above  essay  made  an  enormous  differ- 
ence in  the  value  attributed  to  so-called  mechanical  causes.  Nowadays 
a  more  rational  view  is  taken  of  the  importance  of  alterations  or  devia- 
tions from  the  ordinary  position  of  the  womb ;  and  it  is  recognised  that 
very  considerable  changes  in  the  position  of  the  uterus  are  perfectly 
compatible  with  the  enjoyment  of  excellent  health.  The  outcome  on 
the  clinical  aspect  is  easy  to  imagine  ;  pessaries  are  no  longer  recklessly 
inserted  for  every  slight  misplacement,  but  are  retained  for  those  more 
severe  cases  in  which  relief  to  an  embarrassed  circulation  is  clearly 
called  for. 

The  Pelvic  Peritoneum.  —  Good  work  has  been  done  in  the  past  years 
by  those  who  have  increased  our  knowledge  of  the  anatomical  and  obstet- 
ric aspects  of  the  pelvic  peritoneum.  Thus  Polk  and  Barbour  have 
shown  that  in  the  full-term  pregnant  uterus  the  peritoneum  in  front  and 
behind  has  the  same  relations  as  in  the  non-gravid  uterus ;  whereas,  at 
the  sides,  the  peritoneum  is  so  lifted  up  by  the  growing  uterus  that  the 
base  of  the  broad  ligament  is  on  the  level  Avith  the  pelvic  brim.  Stephen- 
son concludes  that  the  ligamental  portions  of  the  pelvic  peritoneum 
offer  considerable  and  permanent  resistance  to  stretching  beyond  the 
limits  of  their  elasticity ;  and  that  the  tension  thus  thrown  on  them  is 
sufficient  to  undo  their  attachment  to  the  pelvic  walls.  The  peritoneum 
covering  the  uterus,  hoAvever,  instead  of  borrowing  from  neighbouring 
parts,  undergoes  a  gradual  yielding  to  an  unlimited  extent  —  growth 
supplying  the  additional  material  necessary  to  prevent  thinning.  The 
contrast  is  great  between  the  unlimited  expansion  of  the  uterine  peri- 
toneum, under  the  gradual  increase  in  bulk  of  the  ovum  and  its  intol- 
erance of  a  rapid  dilating  force  —  a  contrast  aptly  illustrated  in  the 
history  of  the  induction  of  premature  labour  by  tlie  rupture  of  the 
uterus  on  the  injection  of  but  a  few  ounces  of  water.  The  peculiar 
property  of  the  uterine  peritoneum  of  gradually  yielding  under  a  small 
but  persistent  force,  while  breaking  under  a  sudden  one,  confers  upon  it 
something  of  a  plastic  character.  Dr.  Stephenson  remarks :  "  Such  being 
the  properties  of  the  serous  coat,  it  is  evident  that  it  must  play  a  part 
in  the  dynamics  of  the  uterus.  It  furnishes  a  part  of  the  persistent 
pressure  inside  the  organ.  It  is  also  capable  of  taking  a  share  in  the 
retraction  of  the  uterus.  Whatever  be  the  state  of  the  muscular  fibres 
of  the  uterus  when  labour  is  over,  they  are  surrounded  and  supported  by 


SYSTEM  OF  GYNAECOLOGY 


an  elastic  capsule,  ^yitll  which  any  force  tending  to  produce  dilatation 
has  to  reckon.  This  idea  is  strongly  supported  by  the  anatomical  fact 
that,  in  the  portion  of  the  uterine  walls  where  reaction  is  manifested, 
the  peritoneum  is  firmly  attached ;  whereas  the  parts  where  uo  active 
retraction  occurs  have  either  no  peritoneal  covering,  or  that  membrane 
is  but  loosely  attached  thereto." 

The  knowledge  of  this  behaviour  of  the  pelvic  peritoneum  under  the 
disturbing  influence  of  pregnancy  is  of  immense  importance  to  the 
gynaecological  surgeon;  for  it  enables  him  to  estimate  the  probable 
changes  in  the  anatomical  arrangement  of  the  membrane,  when  fibroid 
tumours  or  broad  ligament  cysts  have  developed  in  the  pelvis,  and  have 
materially  affected  the  relations  of  its  parts.  Again,  in  the  rupture  of 
tubal  gestations,  or  in  the  formation  of  pelvic  heematoma  from  other 
causes,  the  effect  of  the  peritoneal  resistance  on  the  development  of 
these  swellings  is  made  clear. 

The  Connective  Tissue  of  the  Pelvis.  —  We  are  greatly  indebted  to  the 
good  work  done  by  Hart  and  Barbour  for  our  accurate  knowledge  of  the 
manner  in  which  the  connective  tissue  of  the  pelvis  is  distributed.  This 
tissue,  lying  subperitoneally,  surrounding  the  cervix  uteri,  and  spreading 
out  between  the  layers  of  the  broad  ligament,  is  of  the  highest  patho- 
logical importance,  as  in  it,  and  in  the  pelvic  peritoneum,  occur  those 
inflammatory  exudations  so  common  in  women. 

Of  late  years  our  knowledge  of  the  disposition  of  this  tissue  has  been 
rendered  much  more  accurate ;  and,  accordingly,  our  discrimination 
of  pelvic  inflammatory  attacks  made  much  more  precise.  The  most 
valuable  information  is  obtained  by  studying  sections  of  frozen  pelves. 
This  method  gives  the  precise  position  of  the  tissue,  its  amount  and  dis- 
tribution. By  injections  of  air,  water,  or  plaster  of  Paris,  we  have  learnt 
the  varying  attachments  of  the  pelvic  peritoneum  to  the  subjacent  tissue; 
and  the  lines  of  cleavage,  as  it  were,  of  the  pelvic  connective  tissue  along 
which  lines  pus  will  burrow.  The  valuable  experiments  of  Bandl, 
Konig,  and  Schlesinger  have  given  us  the  following  results :  — 

1.  Water  injected  between  the  layers  of  the  broad  ligament,  high 
up  in  front  of  the  ovary,  passed  first  into  the  tissue  lying  at  the 
highest  part  of  the  side-wall  of  the  true  pelvis.  It  then  passed  into 
the  tissue  of  the  iliac  fossa,  lifting  up  the  peritoneum,  and  followed  the 
course  of  the  psoas,  passing  only  slightly  into  the  hollow  of  the  iliac 
bone.  Lastly,  it  separated  the  peritoneum  from  the  anterior  abdominal 
wall  for  some  little  distance  above  Poupart's  ligament,  and  fro]n  the 
true  pelvis  below  it, 

2.  On  injection  beneath  the  broad  ligament  to  the  side  and  in  front 
of  the  isthmus,  the  deep  lateral  tissue  became  filled  first;  then  the 
Itcritoneuiri  became  lifted  up  from  the  anterior  part  of  the  cervix  uteri ; 
tlieiico  the  separation  passed  first  to  the  tissue  near  the  bladder; 
ultimately  the  fluid  i^assed  along  the  round  ligament  to  the  inguinal 
ring.  There  it  separated  the  peritoneum  along  tlie  line  of  Poupart's 
ligament,  and  passed  into  the  iliac  fossa. 


THE  DEVELOPMENT   OF  MODERN    GYNAECOLOGY 


3.  An  injection  at  the  posterior  part  of  the  base  of  the  broad  liga- 
ment filled  the  corresponding  tissue  round  Douglas'  pouch  and  then 
passed  on  as  described  in  the  first  section. 

Much  might  be  written  to  show  what  extensive  Avork  has  been  done 
to  perfect  our  knowledge  of  the  sectional  anatomy  of  the  female  pelvis, 
of  the  structural  anatomy  of  the  pelvic  floor,  and  of  the  position  of  the 
uterus  and  its  appendages ;  but  the  work  already  quoted  will  illustrate 
how  full  a  share  anatomy  has  had  in  the  development  of  gynaecological 
science. 

Turning  from  the  anatomical  to  the  pathological  and  clinical  aspects, 
it  is  interesting  to  note  that  the  enormous  strides  which  the  science 
has  made,  and  which  have  raised  it  from  a  desultory  collection  of 
hypotheses  to  its  present  high  position,  have  all  been  taken  in  the 
last  half  century.  It  is  true  that  in  the  early  part  of  the  century 
Recamier  was  advocating  the  use  of  the  speculum  and  sound,  and  by  his 
writing  and  teachings  was  given  an  impulse  to  the  study  of  uterine 
pathology ;  but  it  was  not  until  about  the  year  1840,  when  Simpson  in 
]*]ngland  and  Huguier  in  France  took  the  field  with  so  much  warmth, 
vigour,  and  originality,  that  interest  was  awakened  and  the  future  of 
gynaecology  assured.  Recamier,  Lisfranc,  Kiwisch,  Huguier,  Simpson, 
and  others  had  already  paved  the  way  for  further  discoveries,  when 
Dr.  H.  J.  Bennet,  in  1845,  published  the  first  edition  of  his  work  on 
Inflammation  of  the  Uterus,  and  roused  the  attetition  of  the  profession 
in  every  country  to  the  pathology  which  he  there  set  forth.  The  chief 
points  he  insisted  upon  were  the  following  :  — 

1.  That  inflammation  is  the  chief  factor  in  uterine  affections,  and 
that,  as  results,  there  follow  from  it  displacements,  ulcerations,  and 
affections  of  the  appendages. 

2.  That  menstrual  troubles  and  leucorrhoea  are  merely  symptoms 
of  this  morbid  state. 

3.  That  in  the  vast  majority  of  cases  inflammatory  action  will  be 
found  to  confine  itself  to  the  cervical  canal,  and  not  to  affect  the  body 
of  the  utervis. 

4.  That  the  disease  is  properly  attacked  by  strong  caustics. 

It  is  difficult  for  the  modern  student  to  apprehend  the  conflict  of 
oi)inions  which  arose  over  these  assertions  of  Bennet ;  it  is  sufficient  to 
say  that  his  views  were  strongly  controverted  by  such  able  writers  as 
Tyler  Smith,  Robert  Lee,  West,  and  others ;  and  that  in  the  present 
day  few  gynaecologists  would  be  prepared  to  accept  such  statements 
without  considerable  modifications. 

Thanks  to  the  study  of  microbic  pathology,  much  evidence,  that  in 
those  days  seemed  misty  and  conflicting,  is  read  by  us  now  in  a  totally 
different  sense.  The  knowledge  of  septic  organisms,  the  influence  of 
specific  microbes,  the  conditions  of  tissue-resistances,  have  opened  out 
for  us  new  ideas  and  new  interpretations ;  and  it  is  probably  not  too 
much  to  assert  that  had  l>v.  Bennet  possessed  our  advantages  much  of 
his  pathology  would  have  been  rewritten. 


SYSTEM   OF  GYNECOLOGY 


Another  landmark  in  the  history  of  the  development  of  modern 
gynecology  was  the  publication  by  Dr.  Tilt,  in  1850,  of  his  book  on 
the  subject  of  Ovarian  Inflammation;  later  the  same  writer  put  for- 
ward the  follo'wing  propositions :  — 

1.  That  the  recognised  frequency  of  inflammatory  lesions  in  the 
ovaries  and  in  the  tissues  which  surround  them,  is  of  much  greater 
practical  importance  than  is  generally  admitted. 

2.  That  of  all  inflammatory  lesions  of  the  ovary  those  involving 
destruction  of  the  whole  organ  are  rare ;  while  the  most  numerous,  and 
therefore  the  most  important,  may  be  ascribed  to  a  disease  that  may  be 
called  either  chronic  or  subacute  ovaritis. 

3.  That,  as  a  rule,  pelvic  diseases  of  women  radiate  from  morbid 
ovulation. 

4.  That  morbid  ovulation  is  a  most  frequent  canse  of  ovaritis. 

5.  That  ovaritis  frequently  causes  pelvic  peritonitis. 

6.  That  blood  is  frequently  poured  out  from  the  ovary  and  the 
oviducts  into  the  peritoneum. 

7.  That  subacute  ovaritis  frequently  initiates  and  prolongs  metritis. 

8.  That  ovaritis  generally  leads  to  considerable  and  varied  disturb- 
ance of  menstruation. 

9.  That  some  chronic  ovarian  tumours  may  be  considered  as  aberra- 
tions from  the  normal  structure  of  the  Graafian  cells. 

Much  of  the  pathology  involved  in  these  propositions  of  Tilt  was 
sound,  and  has  stood  the  test  of  time  and  more  extended  research ;  and 
though,  as  in  propositions  three  and  four,  his  teaching  is  not  nowadays 
accepted,  yet  by  it  a  considerable  stimulus  was  given  to  the  study  of 
ovarian  pathology,  and  in  testing  the  truth  of  his  assertions  more  and 
more  light  was  gained.  Morbid  conditions  of  the  tubes  had  been  but 
little  studied  in  Tilt's  time,  and  the  relation  of  tubal  disease  to  ovarian 
inflammation  was  hardly  appreciated ;  had  tubal  pathology  been  better 
understood,  probably  less  weight  would  have  been  attached  to  morbid 
ovulation  as  a  cause  of  pelvic  disease. 

The  year  1854  marked  a  fresh  epoch  in  the  evolution  of  gynaecology ; 
then  it  was  that  the  great  war  of  uterine  displaceynents  and  pessary- 
manufacture  b(!gan.  Hodge  in  America,  Velpeau  in  France,  and  Graily 
Hewitt  in  England,  stood  forth  as  champions  of  the  immense  impor- 
tance of  malposition  of  the  uterus  in  the  causation  of  pelvic  disease. 
How  strongly  the  tlieory  was  urged  may  be  judged  by  Velpeau's  state- 
ment: "  I  declare,  nevertheless,  that  the  majority  of  the  women  treated 
for  other  affections  of  the  uterus  have  only  displacements,  and  I  aflirm, 
that  eighteen  times  out  of  twenty,  patients  suffering  from  disease  of 
the  womb,  or  of  some  other  part  of  this  region,  —  those,  for  instance, 
in  whom  they  diagnose  engorgfiinents,  —  are  affected  by  displacements." 

Graily  Jlewitt,  again,  showed  in  his  writings  and  teachings  the 
enormous  importance  he  attached  to  dis])]acements  of  the  womb;  in  his 
well-known  work  on  JJiseaaes  of  Women  he  formulates  the  following 
opinions :  — 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY  ^ 

"  1.  That  patients  suffering  from  symptoms  of  uterine  inflammation 
are  almost  universally  found  to  be  affected  with  flexion  or  alteration  in 
the  shape  of  the  uterus ;  an  alteration  of  easily  recognised  character 
though  varying  in  degree. 

"2.  That  the  change  in  the  form  and  shape  of  the  uterus  is  fre- 
quently brought  about  in  consequence  of  the  uterus  being  previously  in 
a  state  of  unusual  softness,  or  what  may  be  often  correctly  designated 
as  chronic  inflammation. 

"  3.  That  the  flexion  once  produced  is  not  only  liable  to  perpetuate 
itself,  so  to  speak,  but  continues  to  act  incessantly  as  the  cause  of  the 
chronic  inflammation  present." 

For  a  long  time  the  teaching  and  literature  of  this  epoch  caused  a 
vastly  undue  importance  to  be  laid  on  the  presence  of  every  flexion  or 
deviation,  however  slight.  Every  gynaecologist  or  practitioner  who 
claimed  special  gynaecological  merit,  felt  himself  called  upon  to  invent  a 
pessary  or  to  modify  some  one  else's  instrument ;  and  if,  to  quote  Dr. 
Clifford  Allbutt,  "  the  uterus  could  justly  complain  that  it  was  always 
being  impaled  on  a  stem  or  perched  on  a  twig,"  it  certainly  could  not 
complain  that  there  was  want  of  variety  in  the  stem  or  monotony  in 
the  contour  of  the  twig. 

Thanks  to  a  more  complete  study  of  the  circulation  of  the  uterus  by 
Williams,  and  to  the  teaching  and  practice  of  Matthews  Duncan,  a  more 
correct  appreciation  of  the  importance  of  uterine  displacement  has  been 
arrived  at;  and  we  can  recognise  that  it  is  possible  for  the  uterine  axis, 
as  for  the  nasal  septum,  to  be  somewhat  deviated  without  the  patient's 
health  being  materially  affected  thereby.  The  value  of  a  pessary  in 
suitable  cases  is  fully  allowed ;  but  the  instrument  is  no  longer  thought 
to  be  a  panacea  for  every  pelvic  ill,  or  even  a  justiflable  placebo  to 
soothe  the  patient  when  diagnosis  is  at  fault. 

Surgery.  —  The  next  great  era  in  the  j^r ogress  of  gynoicology  dates  from 
the  establishment  of  ovariotomy  as  a  recognised  operation;  for  abdominal 
surgery,  and  especially  that  branch  of  it  which  had  reference  to  disease 
of  the  uterus  and  its  appendages,  received  its  greatest  impulse  when  it 
was  found  that  ovarian  cysts  of  the  most  formidable  nature  could  be 
dealt  with  successfully  and  safely.  Much  discussion  has  arisen  from 
time  to  time  as  to  whom  the  credit  of  the  first  successful  ovariotomy 
belongs,  but  it  is  now  fairly  certain  that  this  honour  rightly  belongs  to 
Dr.  McDowell  of  Kentucky. 

The  record  of  this  first  operation  is  of  interest ;  it  was  performed  on 
a  Mrs.  Crawford  of  Kentucky,  in  December  1809.  The  tumour  inclined 
more  to  one  side  than  the  other,  and  was  so  large  as  to  induce  her 
professional  attendant  to  believe  that  she  was  in  the  last  stage  of  preg- 
nancy. She  was  affected  with  -[lains  similar  to  those  of  labour  pains, 
from  which  she  could  find  no  relief.  The  incision  was  made  on  the  left 
side  of  the  median  line,  some  distance  from  the  outer  edge  of  the  rectus 
miiscle,  and  was  nine  inches  in  length.  As  soon  as  the  incision  was 
completed  the  intestines  rushed  out  upon  the  table ;  and  so  completely 


8  SYSTEM  OF  GYNECOLOGY 

was  the  abdomen  filled  by  the  tumour,  that  they  could  not  be  replaced 
during  the  operation,  which  was  finished  in  twenty-five  minutes.  In 
consequence  of  its  great  bulk  Dr.  M'Dowell  was  obliged  to  puncture  it 
before  it  could  be  removed.  He  then  threw  a  ligature  round  the  Fallo- 
pian tube  near  the  uterus,  and  cut  through  the  attachments  of  the  mor- 
bid growth.  The  sac  weighed  seven  and  a  half  pounds,  and  contained 
fifteen  pounds  of  a  turbid,  gelatinous-looking  substance.  The  edges  of 
the  wound  being  brought  together  by  the  interrupted  suture  and  adhesive 
strips,  the  woman  was  placed  in  bed  and  put  upon  the  antiphlogistic 
regimen.  '•  In  five  days,"  says  Dr.  M'Dowell,  "  I  visited  her,  and,  much 
to  my  astonishment,  found  her  engaged  in  making  up  her  bed.  I  gave 
her  particular  caution  for  the  future,  and  in  twenty-five  days  she  returned 
home  in  good  health,  which  she  continues  to  enjoy."  Mrs.  Crawford 
lived  until  March  1841,  and  had  no  return  of  her  disease.  She  enjoyed 
excellent  health  up  to  the  time  of  her  death. 

It  must  not,  however,  for  a  moment  be  supposed  that  the  idea  of 
ovariotomy  originated  with  M'Dowell :  years  before,  the  Hunters  had 
shadowed  forth  the  possibility  of  removing  ovarian  cysts;  and  John 
Bell,  of  Edinburgh,  though  he  had  never  performed  ovariotomy,  yet  in 
his  lectures  dwelt  with  peculiar  force  and  pathos  upon  the  hopeless  char- 
acter of  ovarian  tumours  when  left  alone,  and  upon  the  practicability  of 
removing  them  by  operation.  From  this  time  forward  operating  sur- 
geons from  time  to  time  undertook  the  operation :  sometimes  a  solitary 
case,  followed  by  success  or  failure,  sometimes  a  small  group  of  cases 
(as  published  by  Dr.  Clay  of  Manchester  in  1842)  with  a  fair  percent- 
age of  success,  were  recorded ;  but  still  the  operation  had  not  secured 
the  confidence  of  the  profession,  and  the  records  were  few  and  far 
between. 

In  1850  Mr.  Duffin  inaugurated  a  new  era  by  raising  the  question  of 
the  danger  of  leaving  the  tied  end  of  the  pedicle  within  the  peritoneal 
cavity ;  and  by  insisting  upon  the  importance  of  keeping  the  strangu- 
lated stump  outside.  Of  this  step  in  the  history  of  ovariotomy  Spencer 
Wells  writes :  "  Whatever  may  be  our  opinions  and  practice  at  the  pres- 
ent time,  and  whatever  views  we  may  hold  upon  the  question,  whether 
this  extraperitoneal  treatment  of  the  pedicle  has  advanced  or  retarded 
the  success  of  the  operation,  Mr.  Duffin's  arguments  led  to  great  changes 
and  results  —  to  the  use  of  the  clamp  and  to  all  the  modifications  of 
treatment  attendant  upon  it,  and  ultimately  to  researches  as  to  the 
physiological  and  pathological  phenomena  of  ligatured  stumps  within 
the  peritoneal  cavity,  and  to  the  study  of  the  important  subject  of 
drainage  Vjy  Koeberle  and  others." 

Much  might  be  said  of  the  excellent  work  done  by  Baker  Brown,  and 
of  his  success  with  the  cautery;  also  of  Tyler  Smith's  revival  of  the 
practice  of  returning  the  pedicle  with  the  ligature :  but  the  history  of  the 
estaVilished  and  successful  practice  of  ovariotomy  dates  from  the  publica- 
tion of  Sir  Spencer  Wells's  first  book  in  18G4.  From  this  time  onward 
ubdoininal  j)elvic  surgery  has  had  a  continuous  story  of  forward  progress. 


THE  DEVELOPMENT   OF  MODERN   GYNECOLOGY  g 

step  by  step  difficulties  have  been  overcome,  and  each  advance  has  been 
established  on  a  sound  scientific  basis. 

Among  the  many  useful  points  made  clear  by  Spencer  Wells  that 
regarding  the  union  of  divided  peritoneum  was  of  special  interest.  From 
experiments  made  upon  dogs,  rabbits,  guinea-pigs,  and  other  animals,  he 
was  able  to  give  visible  evidence  that,  in  the  union  of  the  cut  surfaces  of 
an  abdominal  incision,  however  accurately  other  tissues  might  be  brought 
together,  if  the  cut  edges  of  the  peritoneum  are  left  free  within  the 
cavity  they  retract,  direct  union  does  not  take  place,  and  secondary  evil 
consequences  result.  On  the  other  hand,  in  specimens  where  the  divided 
edges  or  rather  surfaces  of  peritoneum  have  been  pressed  together,  the 
smooth,  serous,  inner  coat  of  the  abdominal  wall  is  perfectly  restored. 
The  stitches  cannot  be  seen  on  the  inside,  though  plainly  visible  on  the 
skin ;  and  there  is  no  adhesion  of  intestine  or  omentum.  But  in  other 
specimens,  where  the  peritoneal  edges  were  purposely  excluded  from 
the  sutures,  and  the  animal  was  not  killed  for  a  day  or  two,  intestine  or 
omentum  adheres  to  the  inner  surface  of  the  abdominal  wall,  thus  com- 
pleting the  peritoneal  sac  at  the  great  risk  of  intestinal  obstruction ;  to 
say  nothing  of  a  want  of  firm  parietal  union  and  subsequent  ventral 
hernia.  It  was  clearly  demonstrated  that,  when  skin  or  mucous  mem- 
brane is  divided,  the  edges  must  be  brought  together  to  secure  direct 
union.  If  they  are  inverted,  union  is  prevented.  The  exact  opposite 
holds  good  with  serous  membranes.  Their  edges  should  be  inverted 
and  two  surfaces  of  membrane  pressed  together,  so  that  the  sutures  are 
not  seen.  The  effused  lymph  then  makes  so  smooth  a  surface  that 
even  the  line  of  union  cannot  be  seen. 

To  those  of  us  who  have  been  brought  up  in  the  atmosphere  of  modern 
surgery,  when  the  details  of  ovariotomy  are  carried  out  with  almost 
universal  agreement,  it  is  difficult  to  realise  the  fierceness  of  the  fights 
which  raged  round  the  comparative  merits  of  a  long  or  a  short  abdominal 
incision  ;  how  bitterly  the  advocates  of  the  intraperitoneal  treatment  of 
the  pedicle  regarded  those  who  treated  the  pedicle  by  the  extraperitoneal 
method  and  the  use  of  the  clamp,  or  how  great  was  the  importance 
attributed  by  each  operator  to  his  own  special  method  of  closing  the 
wound !  Bit  by  bit  evidence  has  been  accumulated  as  to  the  desirability 
of  using  opium  freely  or  sparingly  after  the  operation ;  as  to  the  best 
mode  of  feeding  the  patient  and  maintaining  her  strength ;  as  to  the 
use  of  stimulants ;  the  modes  of  entry  of  septic  poisoning,  and  the  after 
consequences  and  complications  of  the  operation. 

Ovariotomy  in  the  course  of  its  evolution  taught  us  great  things  regard- 
ing the  tolerance  of  the  peritoneum  even  of  rough  handling  and  injury, 
provided  nothing  septic  be  left  for  absorption.  Many  details  of  treat- 
ment emplo3'ed  at  present  in  abdominal  surgery  were  learnt  in  the  school 
of  ovariotomy.  In  his  address  on  "Abdominal  Surgery  Past  and  Present," 
delivered  before  the  Medical  Society  in  October  1890,  Mr.  Knowsley 
Thornton  attempted  to  sum  up  the  causes  of  slow  progress  and  too  frequent 
failure  in  abdominal  surgery  u})  to  the  year  1876,  and  to  place  the  various 


SYSTE.V  OF  GYNECOLOGY 


causes  in  what  seemed  to  him  to  be  their  order  of  importance.  He  says : 
•'  We  have  tirst  the  general  want  of  cleanliness  and  the  lack  of  all  apprecia- 
tion or  knowledge  of  what  constituted  surgical  cleanliness,  then  the  long 
ligature  and  the  clamp,  both  clumsy  and  unscientific,  and  both  specially 
suited  to  make  the  want  of  cleanliness  more  deadly,  and  then  following 
■with  an  appreciable  but  far  different  influence,  we  have  delay  in  operating, 
tapping,  and  the  long  incision.  Then  I  must  not  forget  drainage,  for  I 
think  it  is  highly  probable  that  a  really  good  system  of  drainage,  such 
as  we  now  have,  thanks  to  Koeberle  and  Keith,  would  have  done  much 
to  counteract  the  evils  I  have  named  above,  though  the  frequent  use  of 
the  drainage  tube,  with  the  long  ligature  and  the  clamp,  Avould  have  in- 
troduced new  elements  of  risk,  which  I  shall  have  to  refer  to  again  when 
I  speak  of  the  place  which  drainage  occupies  in  the  successes  of  to-day." 

Probably  the  long  ligature  and  the  clamp  had  less  to  do  with  failure 
than  the  want  of  knowledge  of  antiseptic  precautions.  At  the  present 
day  we  use  a  clamp  round  the  pedicle  of  a  fibroid  tumour,  we  fix  it  in 
the  lower  angle  of  the  abdominal  wound,  and  yet  we  keep  the  wound 
and  peritoneum  perfectly  free  from  septic  mischief :  moreover,  in  extir- 
pation of  the  cancerous  uterus  per  vaginam  we  tie  broad  ligaments  with 
silk  ligatures,  and  leave  long  ends  hanging  down  into  the  vagina  till 
they  come  away ;  and  yet  we  do  not  get  septic  peritonitis. 

Probably  delay  in  operating  plays  a  more  important  part  in  results 
than  we  have  hitherto  supposed.  The  early  ovariotomists  had  to  under- 
take a  large  percentage  of  cases  of  long  standing,  cases  in  which  the 
patient's  strength  had  been  exhausted  by  years  of  suffering,  and  in  whom 
tissue  resistance  to  the  slighter  or  more  severe  forms  of  septic  attack 
Avas  greatly  impaired;  cases,  moreover,  in  which  dense  and  difficult 
adhesions  to  bowel,  bladder,  liver,  and  neighbouring  parts  had  become 
organised  in  the  long  delay.  At  the  present  time  the  majority  of  these 
difficult  cases  have  been  cleared  off,  and  in  most  of  the  cases  now  under- 
taken the  health  is  still  unimpaired,  and  adhesions  (if  present)  are  soft 
and  easily  separated ;  moreover,  long  experience  has  taught  us  how  to 
discriminate  unsuitable  cases  of  a  malignant  type,  and  these  we  have 
the  wisdom  to  leave  severely  alone. 

No  educated  surgeon  will  ever  minimise  our  vast  obligations  to  Sir 
Joseph  Lister;  but,  in  fairness  to  the  early  operators,  we  may  notice  that 
Sir  Spencer  Wells  had  taken  steps  at  a  very  early  period  to  prevent  the 
exposure  of  his  cases  to  noxious  influences.  He  did  not  allow  surgeons 
who  had  been  in  contact  with  septic  cases  to  be  present  at  his  operations  ; 
he  kept  his  wards  for  abdominal  cases  separate  from  wards  in  which 
patients  with  uterine  sloughing  cancer  or  other  fretid  diseases  were 
present;  and  he  himself  gave  up  all  work  in  the  post-mortem  room. 
The  dawning  of  better  things  in  the  way  of  surgical  cleanliness  had  thus 
been  shadowed  forth  before  the  full  light  of  Lister's  teaching  had  risen 
upon  us.  If  in  descril)ing  thus  far  the  growth  of  ovariotomy  the  names 
of  many  eminent  ])ion(!(!rs,  such  as  Clay  of  Manc^hester,  Atlee  of  America, 
Keith,  and  numerous  otluM-  workers  have  received  scanty  recognition,  it 
is  Vjecause  in  the  present  article  no  attempt  is  being  made  to  describe 


THE   DEVELOPMENT   OF  AIODEKJV   GYNECOLOGY  ii 

fully  the  evolution  of  ovariotomy,  but  only  to  show  the  place  it  took 
in  the  development  of  gynaecological  science,  and  to  emphasise  some 
of  the  principal  teaching  and  the  elaboration  of  details  which  secured 
for  it  the  present  successful  position. 

When  once  the  removal  of  the  ovaries  in  cases  of  cystic  disease  of 
these  organs  had  become  an  established  operation,  it  was  to  be  expected 
that  surgeons  would  consider  the  advisability  of  removing  the  uterine 
appendages  for  other  morbid  conditions :  but  no  special  move  was  made 
in  this  direction  till  about  the  year  1872,  when  we  find  that  Hegar, 
Battey,  and  Lawson  Tait  all  began  to  work  in  this  special  field.  Bat- 
tey's  original  idea  was  to  remove  ovaries,  not  in  themselves  diseased, 
for  the  cure  of  certain  nervous  diseases,  which  he  believed  to  be 
caused  or  kept  up  by  structural  or  functional  derangements  of  the 
ovaries.  Hegar  must  have  the  credit  of  introducing  the  removal  of 
ovaries  for  the  cure  of  fibromyoma  of  the  uterus ;  while  to  Mr.  Law- 
son  Tait  belongs  the  credit  of  introducing  the  operations  for  removal 
of  diseased  ovaries  and  tubes. 

It  is  now  fairly  well  established  that  extirpation  of  the  ovaries  for 
various  neuroses  is  practically  a  failure :  the  operation  has  been  recom- 
mended in  cases  of  insanity  occurring  at  times  of  ovulation,  in  cases 
of  hystero-epilepsy,  also  in  hystero-neuroses  other  than  epilepsy  of  se- 
vere character,  but  in  very  few  instances  has  a  cure  been  reported ;  in 
the  majority  no  good  has  been  gained,  and  in  a  certain  proportion  the 
patient  has  been  left  mentally  and  physically  in  a  worse  condition 
than  before. 

When,  on  the  other  hand,  we  study  the  cases  in  Avhich  the  ovaries 
have  been  removed  for  the  cure  of  uterine  fibromyoma  we  find  that  a 
great  step  has  been  gained,  and  that  Professor  Hegar  has  added  a  val- 
uable resource  to  our  treatment  of  these  tumours.  Knowsley  Thornton 
considers  that  we  owe  an  immense  debt  to  Hegar  for  the  introduction 
of  this  method  of  dealing  with  fibromyomas  ;  that  the  operation  has,  of 
course,  its  risks  and  its  failures,  but  that,  with  care  in  the  selection  of 
proper  cases,  and  with  care  in  the  removal  of  every  particle  of  ovarian 
tissue,  it  is  most  satisfactory  in  its  results,  and  is  one  of  the  most 
thoroughly  scientific  and  valuable  operations  in  the  field  of  abdominal 
surgery.  When  we  come  to  consider  the  removal  of  diseased  ovaries 
and  tubes,  as  recommended  by  Tait ;  and  try  to  gauge  the  degree  in 
which  this  operation  can  be  called  an  advance  in  gynecology,  we  have 
a  difficult  question  to  deal  Avith  —  a  difficulty  mainly  owing  to  the  in- 
temperate zeal  of  many  advocates  of  the  operation.  In  cases  in  which 
tubes  are  filled  with  putrid  or  specifically  diseased  pus,  and  are  dis- 
placed and  badly  adherent;  or,  again,  when  an  ovary  has  become  a 
mere  bag  of  pus,  displaced,  and  fixed  by  adhesions  low  in  the  pelvis, 
operation  is  urgently  called  for  and  should  be  undertaken. 

There  are  cases,  also,  in  Avhich  the  ovaries,  for  a  long  time  the  subject 
of  chronic  inflammation,  may  be  displaced  and  adherent  low  in  the  pel- 
vis; cases  in  which  the  tubes  may  be  slightly  thickened  by  mucoid  de- 
generation, or  are  in  an  early  condition  of  hydrosalpinx :  in  such  cases 


SYSTEM   OF  GYiW-ECOLOGY 


when  the  patient  is  drifting  into  chronic  invalidism,  is  incapacitated 
from  work,  and  is  nnequal  to  the  duties  of  life,  extirpation  is  certainly 
called  for;  On  the  other  hand,  to  remove  ovaries  and  tubes  for  early 
stages  of  sub-acute  ovaritis,  for  slight  degrees  of  pelvic  peritonitis  af- 
fecting the  end  of  the  tube  and  the  ovary,  for  minor  degrees  of  salpin- 
gitis, for  ovarian  prolapse  apart  from  coarse  disease,  is  to  bring  the 
operation  into  well-earned  disrepute,  and  to  retard  rather  than  to  ad- 
vance the  progress  of  the  science.  It  is,  unfortunately,  in  the  very 
cases  in  which  the  operation  is  most  necessary  that  the  greatest  dan- 
ger arises ;  for  it  is  impossible  to  extirpate  tubes  full  of  foul  pus  or 
suppurating  ovaries  without  great  danger  of  fouling  the  peritoneum  : 
moreover,  in  these  cases  the  intestines  are  often  so  adherent,  or  so  soft- 
ened by  inflammation,  that  a  great  risk  of  rupture  or  of  subsequent 
faecal  fistula  must  necessarily  be  run.  It  has  been  well  said  that  if  the 
mortality  could  be  obtained  for  all  the  cases  of  pyosalpinx  operated  upon 
in  the  United  Kingdom  since  Tait  introduced  the  operation,  it  would 
run  the  natural  mortality  of  the  disease  very  close  indeed.  There  are, 
moreover,  sundry  objections  to  the  operation  which  should  be  recognised, 
though  they  are  frequently  ignored.  The  operation  does  not  by  any 
means  always  lead  to  a  permanent  cure :  a  large  proportion  of  patients 
operated  upon  suffer  from  continuance  of  the  pains  which  preceded  the 
operation ;  sometimes  inflammatory  products  are  formed  which  press 
on  nerves  and  thus  cause  fresh  troubles,  or  fix  the  uterus  and  thereby 
cause  intense  pain ;  or  grave  mental  symptoms  may  ensue ;  or  the  ped- 
icle may  suppurate  and  the  healing  of  the  wound  be  gravely  delayed. 

Mr.  Alban  Doran  summed  up  the  position  of  the  operation  very 
satisfactorily  when  he  remarked  that  it  was  very  evident  that  removal 
of  the  appendages  was  an  operation  to  be  avoided  whenever  possible : 
and  Professor  Sinclair  has  wisely  pointed  out  that  operators  are  dis- 
posed to  regard  the  woman's  escaping  with  her  life  as  constituting  per 
se  a  satisfactory  result ;  whereas  more  attention  should  be  paid  to  the 
ultimate  effects  upon  the  general  health. 

In  connection  with  this  operation,  we  may  properly  consider  the 
work  done  of  late  years  both  in  Germany  and  in  England,  by  which 
it  has  been  shown  that  in  many  instances  the  mere  breaking  down  of 
adhesions,  without  removal  of  either  tube  or  ovary,  is  quite  sufficient 
to  relieve  the  patient  of  all  her  previous  symptoms,  and  to  restore  her 
to  an  active,  useful  life. 

The  revival  of  ovariotomy  between  1858  and  1805  led,  in  the  words 
of  Paget,  to  an  extension  of  the  whole  domain  of  peritoneal  surgery. 
This  extension,  naturally  enough,  began  with  the  removal  of  the  uterine 
tumours.  The  removal  of  fibromyomas  of  the  uterus  has  always  been  a 
much  more  serious  matter  than  the  y)erformance  of  ovariotomy  :  thus  up 
to  the  end  of  the  year  1883,  or  thei-eabouts,  such  eminent  operators  as 
Hchroeder,  Martin,  Tait,  and  P>antock  liad  a  inortality  of  30  per  cent, 
or  even  higher;  and  though  by  improved  methods  and  wider  experience 
Keith  has  shown  that  it  is  possible  to  have  a  mortality  not  much  greater 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY  13 

than  that  of  ovariotomy,  still  the  operation  in  the  hands  of  the  majority 
of  surgeons  has  not  given  such  satisfactory  results.  The  greatest  gain  so 
far  has  been  brought  about  by  Hegar's  suggestion  of  the  removal  of  tubes 
and  ovaries  as  a  method  of  procuring  arrest  of  growth  and  subsequent 
atrophy  of  these  growths. 

The  rising  generation  of  medical  students  is  much  more  efficiently 
trained  in  obstetrics  and  gynaecology  than  was  the  case  twenty  years 
ago ;  and,  doubtless,  as  fibroids  of  the  uterus  are  recognised  earlier, 
and  cases  of  rapid  growth  of  them  are  better  watched  and  understood, 
Hegar's  method  will  be  applied  in  suitable  cases  with  less  delay,  and 
at  a  time  when  removal  of  the  uterine  appendages  is  more  feasible. 
We  may  thus  hope  less  frequently  to  see  large  fibroid  masses  filling 
the  abdomen  and  calling  for  abdominal  hysterectomy  with  its  greater 
mortality. 

It  is  not  Avithin  the  scope  of  this  article  to  enter  upon  the  various 
methods  of  operating  for  uterine  fibroids,  nor  upon  the  various  modifica- 
tions of  existing  operations ;  but  it  is  noteworthy  that  the  most  eminent 
gynsecological  surgeons  of  the  present  day  are  not  the  most  ardent  advo- 
cates of  frequent  operating,  and  show  their  skill  rather  by  their  judicious 
selection  of  cases  suitable  for  interference.  Again,  there  is  a  decided 
tendency  to  prefer  removal  by  abdominal  section  to  any  form  of 
vaginal  operation ;  save  in  cases  where  submucous  fibroids  have  already 
been  partially  delivered.  As  to  the  treatment  of  the  pedicle  of  the 
tumour,  when  the  growth  is  removed  by  abdominal  incision  operators 
are  still  divided  in  their  choice  between  the  extraperitoneal  method  and 
the  intraperitoneal  as  advocated  by  Schroeder.  Probably  it  will  be 
found  that  each  method  has  its  advantages,  and  that  the  choice  of 
method  must  be  decided  rather  by  the  nature  of  the  growth  than  by  the 
fancy  of  the  operator.  While  on  the  subject  of  fibromyoma  of  the 
uterus,  it  is  impossible  not  to  refer  to  the  electrical  treatment  of  fibroids 
which  has  been  brought  forward  by  Dr.  Apostoli  during  the  last  few 
years.  Many  years  ago  it  was  asked  whether  fibroid  tumours  could  be 
dispersed  by  the  use  of  the  galvanic  current,  but  no  satisfactory  reply 
could  be  obtained.  Apostoli  lias  come  forward  claiming  that  he  has 
found  a  means  of  applying  currents  so  strong  that  destruction  and 
shrinkage  of  the  tumour  is  obtained  without  any  damage  to  the  patient's 
healthy  tissues.  According  to  his  method,  the  operator  applies  a  large 
clay  pad  over  the  abdomen  in  which  is  embedded  the  positive  pole  of  a 
galvanic  battery ;  then  a  sound,  made  of  platinum  Avith  the  lower  part 
protected  by  some  insulating  covering,  is  passed  through  the  cervix  into 
the  uterus ;  or,  Avhere  this  is  impossible,  a  sharp-pointed  steel  sound,  Avith 
all  but  the  terminal  half  inch  insulated  by  a  protective  coating,  is  plunged 
through  the  vaginal  wall  into  the  substance  of  the  tumour :  the  connec- 
tions are  noAv  made,  and  a  current,  varying  from  50  to  100  milliamjieres 
or  more,  is  alloAved  to  pass.  With  reasonable  care  currents  of  this 
strength  can  be  used  Avithout  any  damage  to  the  Avail  of  th(>.  abdomen. 
Many  cases  Avere  brought  forward  by  Apostoli  to  sIioav  \is  that  under 


14  SYSl'EM   OF   GYNAECOLOGY 

this  treatment  fibroids  commonly  shrink  down  to  half  or  a  third  of 
their  original  bulk,  and  in  many  instances  are  practically  destroyed  with- 
out an}^  sloughing  or  suppuration.  The  method  has  been  fairly  tested  by 
nujiierons  oi)erators  since  its  introduction,  and  it  is  to  their  results  that 
we  must  look  in  deciding  whether  this  electrical  treatment  of  fibroids  is 
to  be  regarded  as  an  advance  in  our  knowledge  and  modes  of  treatment 
or  not.  So  far  as  can  be  decided  at  present,  the  result  of  the  most  recent 
inquiries  has  led  us  to  the  following  conclusions :  — 

1.  The  majority  of  fibromyomas  (especially  those  of  slow  growth)  are 
not  reduced  by  the  treatment. 

2.  Soft  fibromyomas  are  somewhat  reduced  in  size  by  the  use  of  the 
current. 

3.  Haemorrhage  due  to  siibmucous  fibroids,  or  perhaps  to  the  fun- 
gous endometritis  so  often  associated  with  them,  is  greatly  lessened. 
In  these  cases  the  positive  pole  is  introduced  into  the  uterine  cavity, 
and  the  negative  is  connected  with  the  abdominal  pad. 

4.  Considerable  damage  may  be  done  to  tissues  in  using  this  treatment. 
The  opponents  of  Apostoli's  method  have  pointed  out  that  fibroid 

tumours  of  the  uterus  (especially  the  soft  cellular  form)  may  be  reduced 
quite  as  satisfactorily  by  the  use  of  rest,  hot  douches,  and  ergot,  as  by 
the  use  of  electricity  ;  and  with  much  greater  safety.  Also  that  the 
shrinkage  obtained  by  the  use  of  the  current  is  by  no  means  permanent. 
Again,  as  regards  haemorrhage,  the  happiest  results  often  follow  the  use 
of  dilatation  and  curettage,  so  that  there  is  no  special  advantage  in 
employing  the  electrical  treatment.  Keith  and  other  observers  have 
spoken  in  terms  of  warm  commendation  of  Apostoli's  work,  but  so  far 
they  have  not  brought  forward  results  which  carry  general  conviction. 
More  extended  observation  is  needed,  but  at  present  it  can  hardly  be 
said  that  the  electrical  treatment  of  fibromyoma  of  the  uterus  ranks 
high  among  our  gains  \yide  art.  "  The  Electrical  Treatment  of  Diseases 
of  Women"]. 

ExtrcirUterine  Pregyiancy.  — One  of  the  results  of  the  recent  advances 
in  abdominal  surgery  has  been  to  give  us  a  wider  acquaintance  with  the 
pathology  and  treatment  of  those  interesting  cases  in  which  the  foetus  is 
developed  outside  the  uterine  cavity.  Much  of  our  present  knowledge  is 
due  to  the  investigation  of  Mr.  Lawson  Tait.  Since  Tait's  first  operation 
in  1S<S3  for  ruptured  ectopic  gestation  —  an  operation  which  he  performed 
successfully  —  great  attention  has  been  directed  to  the  subject,  and  miich 
advance  in  our  knowledge  has  been  made.  Before  this  epoch  extra-uterine 
gestation  was  thought  to  be  one  of  the  rarest  events  in  the  pathology  of 
yjregnancy  :  now  we  know  that  the  accident  is  one  of  common  occurrence. 
The  older  text-books  taught  much  that  was  purely  hypothetical  on  the 
subject;  thus  they  recognised  a  variety  in  which  conception  was  affirmed 
to  occur  in  the  Cxraafian  follicle,  and  development  to  take  place  entirely  in 
the  ovary.  'I'ait  pointed  out  that  no  museum  specimen  or  post-mortem 
record  gives  any  ground  for  such  a  view. 

Again,  regarding  the  so-called  aljdominal  form  of  ectopic  gestation,  it 


THE   DEVELOPMENT   OF  MODERN   GYNECOLOGY  15 

was  believed  that  an  ovum  might  be  fertilised,  drop  into  the  peritoneal 
cavity  on  its  way  to  the  tubal  opening,  and  grow  from  its  beginning 
free  in  the  peritoneal  cavity.  Without  saying  that  this  is  impossible, 
we  may  assert  that  in  our  present  state  of  knowledge  the  notion  is 
purely  imaginary,  and  is  not  borne  out  by  any  evidence  of  dissections. 
More  extensive  research  and  observation  has  led  us  to  view  almost 
every  case  as  primarily  tubal,  commencing  either  —  (i.)  In  the  fim- 
briated end  of  the  tube;  or  (ii.)  in  the  centre  of  the  tube;  or  (iii.)  in 
the  interstitial  part  of  the  tube. 

Much  light  has  been  thrown  on  the  etiology  of  blood  tumour  in  the 
pelvis  by  abdominal  sections  undertaken  for  ruptured  tubal  gestation ; 
and  now  it  is  clear  that  the  majority  of  pelvic  haematoceles  and  haema- 
tomas  are  due  to  blood  poured  out  from  the  end  of  the  tube  after  rupture 
of  the  gravid  tube  or  separation  of  the  sac  wall :  in  a  few  cases  only 
can  it  be  traced  to  such  other  causes  as  reflex  of  menstrual  blood, 
haemorrhagic  peritonitis,  rupture  of  veins  in  the  broad  ligament,  and  the 
like.  jSTo  great  advance  has  been  made  in  our  knowledge  of  the  causes 
which  lead  to  the  production  of  an  extra-uterine  gestation ;  but  the 
hypothesis  which  has  gained  the  widest  hearing  is  that  it  is  due  to 
some  lesion  in  the  interior  of  the  tube  which  obstructs  the  ovum  in  its 
passage  to  the  uterus.  This  lesion  is  in  some  cases  a  desquamation  of 
the  epithelium  of  the  tube,  whereby  the  cilia  are  removed,  and  a  pouch- 
ing of  the  tube  may  be  produced  in  which  the  ovum  remains  instead  of 
continuing  its  journey  to  the  womb.  In  other  cases  a  stenosis  of  the 
lumen  of  the  tube  is  brought  about  by  peritonitic  adhesions  which,  in 
the  course  of  their  contraction,  produce  an  angular  bend  in  the  tube,  and 
so  arrest  of  the  ovum.  The  theory  of  lesion  in  the  interior  of  the  tube 
seems  to  cover  a  large  number  of  cases ;  and  it  is  strengthened  by  the 
fact  that  a  history  of  previous  trouble  on  the  same  side  of  the  pelvis 
can  frequently  be  elicited.  The  event  is  often,  though  not  always,  pre- 
ceded by  a  period  of  sterility.  The  theory  is  also  supported  by  the 
further  supposition  that  the  normal  site  of  impregnation  is  in  the  uterus, 
and  that  if  the  ovum  be  delayed,  and  impregnated  in  the  tube,  ectopic 
gestation  results.  Cases  of  ruptured  tubal  gestation,  when  examined 
on  the  post-mortem  room  table  or  during  an  abdominal  operation,  have 
taught  us  to  Avhat  an  extreme  degree  the  ruptured  peritoneum  may  be 
lifted  from  the  pelvic  walls  and  viscera  by  the  gradual  development  of 
the  foetus,  or  by  repeated  hemorrhages  beneath  the  membrane.  This 
elevation  may  reach  as  high  as  the  umbilicus  or  even  further. 

In  a  paper  read  before  the  Eoyal  Medical  and  C'hirurgical  Society 
of  London,  IMr.  Bland  Sutton  dreAv  attention  to  the  fact  that  the  ovum 
in  a  case  of  tubal  pregnancy,  like  the  ovum  in  uterine  pregnancy,  is 
liable  to  become  converted  into  a  mole  (apoplectic  ovum).  In  Novem 
ber  1892  the  same  author  brought  a  communication  on  "  Tubal  Moles 
and  Tubal  Abortion"  before  the  Medical  Society  of  London,  and  by  his 
admirable  drawings  and  accurate  research  added  greatly  to  our  know- 
ledge of  this  important  condition. 


i6  SYSTEM  OF  GYNECOLOGY 

On  the  subject  of  tubal  moles  Bland  Sutton  says:  "The  retention 
of  an  impregnated  ovum  iu  the  Fallopian  tube  leads  to  occlusion  of  the 
abdominal  ostium,  an  event  usually  complete  by  the  sixth,  but  often 
delayed  to  the  eighth  week  following  impregnation.  It  is  therefore 
comparatively  a  slow  process.  When  the  ovum  is  lodged  in  the  ampulla 
of  the  tube  the  ostium  cannot  close.  So  long  as  the  tubal  ostium  re- 
mains open  the  ovum  is  in  constant  jeopardy  of  being  extruded  through 
it  into  the  peritoneal  cavity,  especially  when  the  ovum  lies  near  or  in 
the  ampulla  of  the  tube.  When  an  impregnated  ovum  is  thus  extruded 
from  the  tube  into  the  general  peritoneal  cavity,  it  is  invariably  in  the 
condition  of  a  mole,  and  the  accident  is  always  accompanied  by  haem- 
orrhage. The  extrusion  of  a  mole  in  this  way  is  always  indicated  by 
the  term  '  tubal  abortion.'  Free  haemorrhage  may  occur  from  a  gravid 
tube  and  the  mole  be  still  retained  in  consequence  of  its  attachment  to 
the  wall  of  the  tube.  Under  such  conditions  the  bleeding  may  be 
repeated.     This  is  known  as  '  incomplete  tubal  abortion.'  " 

Since  the  discovery  of  the  tubal  mole,  specimens  of  occluded  Fal- 
lopian tubes  filled  with  blood,  independent  of  tubal  pregnancy,  are  noAv 
found  to  be  infrequent.  In  the  last  report  of  the  Museum  of  the  Royal 
College  of  Surgeons  (1892),  a  description  is  given  of  "  An  unequivocal 
example  of  Heematosalpinx."  This  is  a  fair  indication  of  the  revolution 
which  has  taken  place  in  our  knowledge  of  the  early  stages  of  tubal 
pregnancy.  There  is  one  point  in  the  treatment  of  ectopic  gestation, 
advanced  to  term  and  in  which  the  foetus  is  still  living,  which  requires 
further  study,  and  this  is  the  treatment  of  the  placenta  after  incision  of 
the  sac  and  extraction  of  the  child.  To  strip  off  the  after-birth  from 
the  underlying  tissues  would  usually  involve  a  terrible  haemorrhage  and 
probably  the  death  of  the  patient ;  yet  to  leave  the  placenta  means,  in 
too  many  instances,  secondary  septic  changes  and  the  death  of  the 
mother.  Lawson  Tait  has  recommended  that  the  cord  should  be  cut 
off  close  to  the  placenta,  the  sac  washed  out,  and  then  sealed  by  stitch- 
ing it  over  the  placenta ;  the  abdomen  is  then  to  be  closed,  and  the 
after-birth  left  to  be  absorbed. 

The  establishment  of  ovariotomy,  leading  as  it  did  to  the  great  exten- 
sion of  peritoneal  surgery,  has  led  us  to  another  great  advance,  namel}^, 
to  the  recognition  of  the  benefits  of  abdominal  drainage.  Operators  differ 
greatly  in  their  estimate  of  the  value  of  the  drainage  tuVje  in  al)donuiial 
surgery,  but  few  in  the  present  day  will  be  found  to  deny  its  value  in 
suitable  cases.  Whether  in  the  treatment  of  pelvic  abscess,  in  the 
case  of  suppurative  or  tubercular  peritonitis,  or  again  after  the  removal 
of  f(Btid,  closely  adherent  pelvic  cysts,  the  drainage  tube  becomes  of 
primary  importance.  For  some  time  the  question  was  debated  whether 
an  incision  made;  into  the  vaginal  roof  to  allow  of  a  canula  being 
di-awn  tlirongli  from  tlie  pcu'itoneal  cavity  into  the  vaginal  canal  wore  not 
the  better  method  of  drainage;  but  it  has  been  fairly  well  proven  by 
Keith,  Alban  iJoran,  and  other  authorities,  that  the  cavity  of  the  peri- 
toneum can  be  more  effectually  emptied  and  kept  free  of  exuded  fluid  by 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY  17 

the  glass  drainage  tube  passed  down  from  the  abdominal  wound  into  the 
floor  of  Douglas'  pouch.  Of  course  in  some  cases  the  use  of  the  rubber 
tube  or  of  iodoform  gauze  may  possess  a  special  advantage.  No  one  who 
has  witnessed  the  good  effects  of  abdominal  drainage  will  doubt  that  in 
the  recognition  of  this  surgical  expedient  we  have  made  a  distinct 
addition  to  our  surgical  knowledge. 

No  account  of  the  work  done  in  the  development  of  gynaecological 
science  would  be  complete  without  a  reference  to  the  sjjlendid  achieve- 
ments of  Marion  Sims  in  the  field  of  vesico-vaginal  fistula.  In  numbers 
of  women  life  was  rendered  one  long  period  of  suffering  and  distress 
until  Sims  brought  his  skill  to  bear  on  the  subject  of  these  lacerations. 
It  is  not  difficult  to  picture  the  constant  mental  agony  of  a  young  woman, 
still  in  the  prime  of  life,  in  whom  the  discomfort  due  to  incontinence  of 
urine  and  the  foetor  depending  on  clothes  soaked  with  decomposing  urine 
were  horrors  from  which  she  could  never  escape.  From  the  days  of 
Ambrose  Pare  attempts  had  been  made  by  Lallemand,  Eoux,  Gosset, 
Jobert  cle  Lamballe,  and  many  other  surgeons,  to  find  a  satisfactory  mode 
of  closing  these  fistulas;  but  with  what  amount  of  success  may  be  judged 
by  the  words  of  Velpeau,  who,  writing  in  1830,  says :  "  To  abrade  the 
borders  of  an  opening,  when  we  do  not  know  where  to  grasp  them  ;  to 
shut  it  up  by  means  of  needles  or  thread,  when  we  have  no  point 
apparently  to  secure  them;  to  act  upon  a  movable  partition  placed 
between  two  cavities,  hidden  from  our  sight,  and  upon  which  we  can 
scarcely  find  any  purchase,  seems  to  be  calculated  to  have  no  other 
result  than  to  cause  unnecessary  suffering  to  the  patient." 

In  1852  Sims  brought  out  his  perfected  method  of  healing  these 
rents  in  the  floor  of  the  bladder ;  and  gained  a  series  of  successes  which 
entirely  altered  the  aspect  of  this  special  domain  of  surgery.  He  laid 
claim  to  three  discoveries ;  namely,  that  he  had  produced  a  speculum 
which  enabled  an  operator  to  explore  the  vagina  perfectly ;  that  he  had 
found  a  suture,  which  was  not  liable  to  set  up  inflammation  or  ulcera- 
tion; and  that  by  the  use  of  his  catheter,  the  bladder  could  be  kept 
empty  during  the  healing  of  the  fistula. 

Sims  was  shortly  afterwards  followed  by  Simon  of  Germany,  and  to 
the  efforts  of  these  two  workers  we  owe  our  present  satisfactory  know- 
ledge of  the  subject.  Simon  himself  laid  great  stress  on  the  importance 
of  the  operation  called  by  him  kolpokleisis,  or  closure  of  the  vagina —  an 
operation  to  be  resorted  to  in  cases  in  which  the  cure  of  a  vesico-vaginal 
fistula  could  not  be  successfully  accomplished.  Doubtless  such  a  surgical 
resource  may  be  fouiid  valuable  occasionally;  but  the  cases  must  be  rare 
in  which  the  fistula  cannot  be  closed  by  patience  and  perseverance.  Year 
by  year,  however,  fewer  cases  of  these  fistulous  o})euiugs  occur.  Better 
h,ygienic  siirroundings  have  told  favourabh'  on  the  young  girls  of  the 
present  day,  and  pelvic  contractions  are  less  frequent ;  the  frequent  use 
of  the  midwifery  forceps  and  their  earlier  application,  prevent  the  foetal 
head  from  resting  so  long  on  the  mother's  soft  parts,  and  prevent  the 
sloughing  of  her  anterior  pelvic  tissues ;  and  an  increased  knowledge  of 

c 


SYSTEM  OF  GYNECOLOGY 


the  mechanism  of  delivery  has  led  to  a  more  successful  management  of 
difficult  labours. 

Reference  may  be  made  here  to  certain  plastic  operations  which  have 
been  devised  in  connection  with  the  vagina;  for  instance,  plastic  opera- 
tions for  lessening  the  calibre  of  the  vagina,  others  for  preventing  prolapse 
of  the  uterus,  plastic  operations  on  the  cervix,  and  so  forth,  but  none  of  them 
has  taken  a  very  firm  holdonthe  surgical  world.  In  the  same  category  might 
be  placed  sundry  operations  which  have  been  devised  of  late  years  for  fix- 
ing the  uterus ;  thus  Alexander's  operation  of  shortening  the  round  liga- 
ments in  cases  of  uterine  prolapse,  hysteropexy  or  fixation  of  the  womb  to 
the  posterior  surface  of  the  parietal  peritoneum,  detachment  of  the  vagina 
from  the  anterior  wall  of  the  uterus  with  opening  of  the  anterior  peri- 
toneal cul-de-sac,  and  forward  fixation  of  the  uterus  —  these  and  sundry 
other  operations  have  all  their  earnest  advocates,  but  I  have  not  given 
them  a  recognised  place  in  uterine  surgery ;  for  it  cannot  be  said  as  yet 
that  they  have  secured  the  confidence  of  the  gynaecological  world ;  they 
are  rather  on  their  trial  than  accepted  as  proven  remedies. 

Malignant  Diseases.  — The  ancient  writers  were  doubtless  acquainted 
with  cancer  of  the  uterus,  but  their  knowledge  was  narrowly  limited ; 
and  we  may  certainly  claim  that  in  the  last  fifty  years  we  have  made 
great  advances  in  our  knowledge  of  the  pathology  and  clinical  course 
of  malignant  diseases  of  the  female  genital  organs.  It  is  a  matter  of 
extreme  regret  that  we  have  hitherto  made  so  little  progress  in  our 
modes  of  treatment,  aud  are  still  so  far  from  an  acquaintance  with  any 
curative  method. 

Even  in  the  earlier  part  of  the  present  century  the  knowledge  of 
uterine  cancer  was  very  shadowy ;  for  Church,  writing  in  1864,  says : 
"  If  we  compare  the  writings  of  different  persons,  and  those  men  of  great 
experience,  we  shall  find  many  points  of  interest  undetermined,  and 
others  the  subject  of  incessant  controversy.  Very  frequently  the  descrip- 
tion of  the  disease  conveys  only  a  lively  picture  of  the  uncertainty  of  the 
writer ;  and  so  vague,  indeed,  is  the  sense  in  which  the  term  cancer  is 
sometimes  applied,  especially  by  the  French  authors,  that  it  would  be 
quite  impossible  to  recognise  the  complaint  from  their  description."  Den- 
man  fully  appreciated  the  uncertainty  of  the  description  generally  given. 
He  says  :  "  C)f  cancer  it  is  to  be  lamented  that  we  have  at  present  neither 
a  tolerable  definition  nor  a  correct  history,  nor  any  accurate  distinction 
of  the  several  varieties  which  are  certainly  known  to  exist.  Nor  is 
it  yet  proved  whether  cancer  of  any  part  has  any  specific  quality  ac- 
cording to  the  structure  of  the  part  affected ;  nor  have  we,  in  fact,  any 
other  idea  than  that  it  is  an  incurable  disease.  Till  within  quite  recent 
years  cancer  was  often  confounded  with  fil)roi(l  tumour  of  the  uterus,  and 
the  division  into  scliin-us,  encephaloid,  epithelioma,  and  colloid  was  com- 
monly quoted  in  the  text-books  of  the  day.  Moreovei',  the  t(!rm  'cor- 
roding ulcer'  was  ai)plied  by  Dr.  John  Clark,  and  subsequently  Sir 
Charles  Clark,  to  a  form  of  ulcer  of  the  cervix  in  which  nothing  but  I'apid 
destruction  of  tissue  is  noticed  as  a  pathological  lesion ;  in  which  there 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY  19 

is  no  hardness  of  the  part  affected,  no  induration  nor  inflammation  of  sur- 
rounding organs  —  nothing  but  molecular  death  in  the  cervix  uteri,  and 
disappearance  of  its  structure  as  by  liquefaction.  It  has  been  described 
under  the  names  of  rodent  ulcer,  diffuse  iilcerative  cancer,  epithelial 
cancer,  and  cancroid  of  the  uterus."  Many  other  authors  might  be 
quoted  to  show  how  little  certainty  existed. 

A  decided  step  in  advance  was  taken  when  Thiersch  and  Waldeyer 
laid  down  that  all  cancerous  disease  in  the  uterus  takes  its  origin  from 
the  epithelium  lining  glands  which  dip  down  into  the  parenchyma. 
"  Only  Thiersch,  and  recently  Waldeyer,"  says  Billroth,  "  maintain  as 
I  do  the  strict  boundary  between  epithelial  and  connective  tissue  cells. 
I  only  call  those  tumours  true  carcinomata  which  have  a  formation  similar 
to  that  of  true  epithelial  glands  (not  the  lymphatic  glands),  and  whose 
cells  are  mostly  actual  derivatives  from  true  epithelium."  At  one  time 
surgeons  Avere  doubtful  whether  malignant  disease  arose  more  often  in 
one  part  of  the  uterus  than  in  another;  but  another  advance  was  made 
when  Sir  Charles  Clark  wrote  that  "carcinoma  particularly  affects 
glandular  parts,  and  the  cervix  of  the  uterus  being  the  most  glandular 
part  of  it,  is  probably  the  reason  why  it  becomes  more  liable  to  this 
disease  than  any  other  part  of  the  viscus." 

Before  this  time  Dr.  Burns  had  laid  down  in  his  work  that  "  as 
opportunities  are  not  frequent  of  examining  the  womb  in  the  early  stage 
of  the  disease,  and  as  in  course  of  time  it  involves  parts  not  at  first 
affected,  we  have  not  yet  decided  what  the  comparative  liability  of 
different  parts  of  this  viscus  is  to  the  disease."  Virchow  advanced  our 
knowledge  still  further  by  his  investigations  into  the  differences  between 
malignant  cauliflower  excrescences  and  non-malignant  papilloma.  He 
stated  his  belief  that  some  tumours,  in  every  respect  resembling  vege- 
tating epithelioma,  are  really  non-maliguant  papilloma.  The  difference 
between  the  latter  and  real  epithelioma  is  to  be  found  by  microscopic 
examination  of  the  submucous  tissue,  which  in  the  one  case  is  healthy, 
in  the  other  case  diseased.  In  1888  Williams  published  his  well-known 
Harveian  Lectures  on  uterine  cancer,  and  summed  up  fairly  the  extent 
of  our  present  knowledge. 

Three  varieties  of  malignant  disease  affect  the  uterus  —  sarcoma,  car- 
cinoma, and  adenoma.  In  the  uterus  sarcoma  and  carcinoma  are  always 
malignant;  adenoma  often,  but  perhaps  not  always.  The  uterus  is  divided 
into  three  parts,  mainly  according  to  the  character  of  the  e})itheliuni  and 
of  the  glands  met  with  in  each  part.  The  first  is  the  vagnial  portion :  this 
portio  vaginalis  is  really  a  cup  of  stratified  epithelium,  resembling  a 
tailor's  thimble,  which  fits  on  the  lower  end  of  the  cervix  proper.  The  next 
part  is  the  cervix,  and  the  third  is  the  part  above  which  constitutes  the 
body  and  fundus  of  the  organ.  These  divisions  are  of  importance  because 
cancer  may  begin  in  any  one  of  them,  and  the  disease  generally  presents 
different  characters,  runs  a  different  course,  and  is  amenable  to  treatment 
in  different  degrees,  according  as  it  begins  in  one  or  other  of  them. 

In   the   first   division  the  disease   is   almost   always   a   squamous 


SYSTEM   OF  GYNAECOLOGY 


epithelioma.  In  this  ease  the  lines  of  growth  are  not  towards  the  cavity 
of  the  uterus,  but  outwards  and  downwards  towards  the  vagina ;  it 
creeps  towards  the  vaginal  vault,  and  then  down  along  the  surface  of 
the  vaginal  walls.  There  is  no  evidence  that  laceration  of  the  cervix 
plays  any  part  in  the  etiology  of  this  form,  of  cancer ;  but  most  of  the 
cases  occur  in  women  who  have  borne  children. 

In  the  second  division  Ave  find  disease  occurring  with  much  greater 
frequency.  The  starting-point  of  the  cancer  of  the  cervix  seems  to  be 
always  in  the  glands  of  the  cervix  ;  and  if  we  study  the  lines  of  growth 
of  the  disease,  we  find  that  it  usually  spreads  doAvn wards  and  outwards 
into  the  surrounding  cellular  tissue.  The  vaginal  walls  are  usually 
spared. 

In  the  third  division  we  have  cases  of  cancer  of  the  body  of  the 
viterus.  This  part  of  the  uterus  is  much  less  commonly  the  seat  of  the 
disease  than  is  the  cervix  ;  at  one  time,  indeed,  it  was  doubted  whether 
cancer  ever  originated  primarily  in  the  body,  but  numerous  undoubted 
cases  have  been  brought  forward  to  prove  the  statement.  All  cancers 
of  the  body  seem  to  be  of  the  columnar  epithelioma  kind.  They  occur 
most  often  after  the  age  of  fifty ;  they  give  rise  at  an  early  period  to 
much  pain  and  flooding ;  they  are  more  common  in  nulliparous  patients, 
and,  once  begun,  they  involve  the  whole  surface  of  the  body,  though 
they  tend  to  respect  the  cervix.  In  the  later  stages  the  disease  passes 
through  the  internal  os  and  attacks  the  cervix ;  it  also  spreads  deeply, 
involves  the  muscular  wall,  and  may  pass  through  it. 

J^o  description  of  the  evolution  of  this  subject  would  be  complete 
without  reference  to  the  admirable  work  done  by  Ruge  and  Veit  in 
investigating  the  true  nature  of  granular  erosions  of  the  cervix,  and  in 
showing  how  these  lesions  differ  from  early  manifestations  of  true  cancer. 
An  erosion  differs  from  cancer  in  that  the  epithelium  on  its  surface 
and  lining  its  glands  consists  of  a  single  layer  and  assumes  no  aberrant 
forms ;  and  from  adenoma  of  the  cervix,  in  that  the  glands  are  compara- 
tively superficial.  A  simple  erosion,  again,  bleeds  less  readily  when 
touched  than  does  the  early  ulceration  of  commencing  malignant  growth. 

As  regards  the  treatment  of  uterine  cancer  but  little  can  be  said. 
During  the  last  ten  or  fifteen  years  a  considerable  controversy  has 
been  raised  concerning  the  rival  merits  of  supravaginal  amputation  and 
total  extirpation  in  cases  of  cervical  carcinoma.  Most  authors  are 
agreed  that  removal  of  the  cervix  is  sufficient  when  the  portio  vagi- 
nalis alone  is  affected ;  but  there  is  not  the  same  agreement  when  the 
disease  attacks  the  upper  part  of  the  cervix.  Martin  of  Berlin  and 
Fritsch  of  Breslau  have  published  numerous  cases  of  total  extirpation 
of  the  uterus  for  cervical  cancer;  but  their  reports,  and  those  of  other 
skilful  operators,  have  only  demonstrated  that  the  operation  can  be  done 
hy  experienced  sui'geons  with  a  very  low  rate  of  mortality.  Williams 
argues  that  in  cases  of  (;ervi(;al  candnoma  sujiravaginal  amputation  does 
all  that  is  needful,  and  that  no  advantage  in  the  prevention  of  r(;currence 
of  tlie  growtli  is  gained  by  the  largcir  operation.     His  views,  however, 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY 


have  by  no  means  met  with  general  acceptance  by  the  profession ;  and 
the  opinion  seems  to  be  gaining  ground  that  if,  in  a  case  of  cancer  of  the 
true  cervix,  an  operation  be  recommended,  total  extirpation  will  prob- 
ably give  the  best  result.  Attempts  at  progress  are  being  made  at 
present  principally  in  the  direction  of  early  diagnosis ;  and  surgeons  are 
endeavouring,  by  microscopical  examination  of  scrapings  removed  Avith 
the  curette,  or  of  sections  taken  from  the  suspected  cervix  with  knife 
or  scissors,  to  gain  early  and  certain  knowledge  while  the  disease  is 
still  narrowly  limited  and  surrounding  tissues  not  invaded. 

Sarcoma  Uteri.  — Very  little  was  known  about  this  affection  by  the 
early  authors  of  this  century.  Eeference  is  found  in  gynaecological 
literature  from  time  to  time  to  certain  forms  of  fibroid  tumours  which 
had  a  tendency  to  return  after  removal ;  and  the  term  "  recurrent  fibroid  " 
was  often  used.  Sir  James  Paget  put  these  tumours  into  three  divisions, 
namely,  (i.)  malignant  fibrous  tumours,  (ii.)  recurrent  fibroids,  (iii.)  mye- 
loid tumours.  Lebert  described  them  as  fibro-plastic  tumours  and  Eoki- 
tansky  gave  them  the  title  of  fasciculated  cancer.  Virchow  was  the  first 
to  give  a  clear  and  intelligent  description  of  these  growths,  and  to  put 
them  under  the  head  of  sarcoma.  GusseroAv  and  other  observers  in  Ger- 
many, following  on  the  steps  of  Virchow,  have  of  late  years  given  careful 
study  to  uterine  sarcoma.  Resembling,  as  it  does,  cancer  of  the  uterus 
in  many  respects,  there  are  certain  well-established  points  of  clinical  dis- 
tinction between  them.  At  one  time  it  was  thought  that  the  disease 
always  arose  in  the  body  of  the  uterus,  and  never  began  primarily  in 
the  cervix ;  but  this  has  now  been  shown  by  Veit  and  others  to  be  a 
mistake,  though  of  course  the  large  majority  of  cases  are  of  the  former 
variety.  Primary  sarcoma  of  the  uterus  occurs  anatomically  and  clini- 
cally in  two  distinct  forms,  namely,  (i.)  fibro-sarcoma,  which  forms  a 
more  or  less  firm,  circumscribed,  rounded  tumour  growing  from  the 
uterine  parenchyma ;  and  (ii.)  diffuse  sarcomatous  tumours  growing 
from  the  connective  tissue  of  the  uterine  mucous  membrane,  and  com- 
posed mostly  of  small  round  cells. 

Between  diffuse  sarcoma  and  carcinoma  of  the  fundus  the  diagnosis 
has  to  be  made  almost  entirely  by  the  microscope.  While  we  have  still 
much  to  learn  regarding  malignant  affections  of  the  genital  organs,  we 
may  congratulate  ourselves  that  our  knowledge  has  become  more  definite, 
better  founded,  and  more  concise.  We  may  here  notice  that  much  know- 
ledge has  been  gained  by  a  more  frequent  use  of  cervical  dilatation;  and 
in  this  respect  much  gratitude  is  due  to  Professor  Hegar  for  his  admir- 
able mechanical  dilators.  It  is  true  that  dilatation  and  curettage  were 
practised  in  the  days  of  Eecamier,  but  not  to  any  considerable  extent.  So 
long  as  surgeons  had  to  trust  to  slow  dilatation  of  the  cervix  with  tents, 
and  had  to  consider  the  risks  of  septic  inflammation  conse(|uent  on  the 
use  of  this  mode  of  opening  up  the  cervix,  the  operation  was  compara- 
tively seldom  resorted  to ;  but  the  present  method  of  rapid  dilatation  has 
removed  much  of  the  ditticulty,  and  has  enabled  iis  to  explore  the  cavity 
of  the  uterus  (puekly  and  safely.     In  cases  of  haemorrhage  occurring  at 


SyS'J'£Jf  OF  GYNAECOLOGY 


or  about  the  time  of  the  climacteric,  cases  in  which  the  uterus  is  found  by 
bimanual  examination  to  be  distinctly  enlarged,  this  method  of  explora- 
tion is  of  immense  service ;  for  it  enables  us  with  the  curette  or  the  finger 
to  remove  small  portions  of  the  hypertrophied  mucous  membrane,  and 
to  determine  promptly  by  the  microscope  whether  the  tissue  be  malignant. 
Believing,  as  now  we  do,  that  some  forms  of  malignant  growth  have  what 
may  be  termed  a  precancerous  stage,  it  becomes  of  immense  importance 
to  ascertain  the  character  of  the  disease  at  an  early  period. 

Xo  great  advance  has  been  made  in  our  knowledge  of  malignant 
affections  of  the  vagina  and  vulva;  but  the  paper  of  Dr.  Matthews 
Duncan  on  lupus  of  the  vulva,  published  in  the  27th  vol.  of  the  Trans- 
actions of  the  Obstetrical  Society  of  London,  has  materially  advanced  our 
knowledge  of  this  rare  disease.  In  this  communication  Duncan 
pointed  out  that  though  vulvar  lupus  lacked  many  of  the  histological 
characters  of  lupus  vulgaris,  yet  in  its  tendency  to  erode  and  destroy  it 
closely  imitated  the  latter  disease.  Lupus  included  ulceration,  inflamma- 
tion, and  hypertrophies,  variously  combined ;  states  which  were  not  can- 
cerous, not  epitheliomatous,  and  not  syphilitic.  It  may  turn  out  that 
several  diseases  are  included  in  this  comprehensive  term  ;  but  at  present 
they  are  combined  in  one  description  on  account  of  their  apparent 
similarity.  They  are  far  from  being  so  uncommon  as  is  sometimes 
supposed. 

Pelvic  Inflammation.  —  In  endeavouring  to  trace  the  development  of 
our  knowledge  regarding  acute  inflammations  occurring  in  the  pelvis,  we 
may  date  our  researches  from  the  year  1840  or  thereabouts.  Before 
this  time,  though  abscess  of  the  womb  had  been  mentioned  by  such 
early  writers  as  Aetius  and  Paul  of  ^^gina,  yet  no  systematic  study  of 
the  affection  had  been  made.  However,  after  the  year  1840  many 
observers  were  at  work.  Thus  in  1841  Bourdon  had  written  on  "  Fluct- 
uating Tumour  of  the  True  Pelvis  "  ;  Doherty  in  1843  had  given  us  his 
views  on  chronic  inflammation  of  the  uterine  appendages ;  Calvi  in  1844 
had  described  "  Intrapelvic  Phlegmonous  Abscess  "  ;  while  in  the  same 
year  Churchill  and  Lever  had  contributed  to  our  knowledge  of  the 
subject.  A  little  later,  in  184G,  Nonat  was  doing  good  work  in  the 
same  field.  Any  one,  however,  who  reads  the  juedical  history  of  these 
times  will  see  clearly  that  the  gynaecologists  of  those  days  were  under 
the  impression  that  all  the  pelvic  exudations  or  abscess  sacs  were  solely 
due  to  inflammation,  or  maybe  to  suppuration,  occurring  in  the  cellular 
tissue  of  the  true  pelvis.  Such  terms  as  pelvic  abscess,  peri-iiterine 
phlegmon,  parametritis,  and  pelvic  cellulitis,  all  meant  practically  the 
same  thing,  namely,  connective  tissue  inflammation.  The  first  advance 
in  our  knowledge  came  through  Pjernutz :  in  1857  a  case  of  so-(!alled  peri- 
uterine phlegmon  came  uiulcr  his  care  and  the  ])atient  died.  At  the 
post-mortem  examination  the  pelvic  tumour  whi(di  had  been  supposed  to 
be  formed  by  inflannnation  of  the  jXilvic  cellular  tissue  was  found  to 
consist  of  bladder,  uterus,  Ijroad  liganuints,  and  sigmoid  flexure  all 
matted  together.     The  cellular  tissue  of  the  broad  ligament  and  uterus 


THE  DEVELOPMENT  OF  MODERN  GYNECOLOGY  23 

was  not  involved,  and  no  real  peri-uterine  phlegmon  existed.  The  study 
of  this  and  similar  cases  caused  Bernutz  and  Goupil  about  the  year  1802 
to  publish  their  classical  memoir,  in  which  abundant  clinical  and  post- 
mortem evidence  was  brought  forward  to  prove  the  true  nature  of  the 
swellings  previously  ascribed  solely  to  the  effect  of  pelvic  cellulitis. 
Bernutz  summed  up  his  views  as  follows:  — 

1.  That  inflammation  of  the  pelvic  peritoneum  is  a  disease  very 
commonly  met  with.  2.  That  the  tumour  found  after  death  in  cases  of 
pelvic  peritonitis  is  formed  by  the  matting  together  of  various  pelvic  vis- 
cera as  a  consequence  of  this  inflammation.  3.  That  inflammation  of  the 
pelvic  serous  membrane  is  always  symptomatic,  and  that  it  is  generally 
symptomatic  of  inflammation  of  the  ovaries  or  of  the  Fallopian  tubes. 

Old  theories,  however,  die  hard ;  and,  though  Bernutz  had  brought 
forward  such  abundant  proof  in  support  of  his  assertions,  yet  for  many 
years  his  views  met  with  little  general  acceptance  by  the  majority  of 
gynaecologists,  and  the  old  views  continued  to  be  taught  and  held. 
Even  such  a  keen  observer  as  the  late  Matthews  Duncan  thought  that 
Bernutz  had  been  over-zealous  in  estimating  the  comparative  frequency 
of  pelvic  peritonitis  and  the  rarity  of  pelvic  cellulitis.  For  some  years 
opinions  were  strongly  divided  upon  the  comparative  frequency  of  cel- 
lulitis and  peritonitis.  With  the  narrowness  and  bitterness  born  of 
imperfect  knowledge,  some  authors  laid  down  strongly  that  in  pelvic 
peritonitis  cellulitis  only  exists  as  a  complication ;  while  others  were  as 
ready  to  assert  that  cellulitis  is  in  all  instances  the  primary  affection, 
and  that  the  inflammation  only  spreads  secondarily  to  the  peritoneum. 
Writing  in  1880  Dr.  Gaillard  Thomas,  however,  records  his  conclusions 
under  four  distinct  propositions,  namely:  — 

''  1.  Peri-uterine  cellulitis  is  rare  in  the  nouparous  Avoman,  while 
pelvic  peritonitis  is  exceedingly  common.  2.  A  very  large  proportion 
of  the  cases  now  regarded  as  instances  of  cellulitis  are  really  cases  of 
pelvic  peritonitis.  3.  The  two  affections  are  entirely  distinct  from  each 
other,  and  should  not  be  confounded  simply  because  they  often  compli- 
cate each  other ;  they  may  be  compared  to  serous  and  parench^'matous 
inflammation  of  the  lungs — pleurisy  and  pneumonia.  Like  them  they 
are  separate  and  distinct,  like  them  the}'  affect  different  kinds  of 
structure,  and  like  them  they  generally  complicate  each  other.  4.  They 
may  usually  be  differentiated  from  each  other,  and  a  neglect  of  the 
effort  at  such  thorough  diagnosis  is  as  reprehensible  as  a  similar  want 
of  care  in  determining  between  pericarditis  and  endocarditis." 

Again,  in  1886,  Hart  and  Barbour  state  that  there  is  now  little 
doubt  that  Bernutz  and  Goupil  pushed  their  views  too  far;  and  tliat  in 
America,  Germany,  and  Britain  gyncBcologists  now  consider  pelvic 
inflanimatiou  as  both  peritonitic  and  cellulitie.  IMoreover,  they  note 
that  both  diseases  are  always  combined.  Thus  in  a  marked  pelvic  peri- 
tonitis there  is  always  some  pelvic  cellulitis,  and  in  a  marked  pelvic 
cellulitis  there  is  always  some  pelvic  peritonitis.  This  is  quite  analo- 
gous to  what  is  found  in  pneumonia  and  pleurisy.     Thus  we  may  fairly 


24  SYSTEM   OF  GYNECOLOGY 

conclude  from  the  result  of  modern  investigations  that  inflammation 
both  of  the  cellular  tissue  and  also  of  the  serouB  membrane  may  arise, 
but  that  of  the  two  the  latter  is  certainly  the  more  frequent. 

Much  good  "work  has  been  done  of  late  years  in  developing  our 
knowledge  of  the  causation  of  pelvic  cellulitis  and  peritonitis.  In  the 
case  of  the  former  disease  recent  investigations  go  far  to  show  that  the 
introduction  of  septic  particles  into  the  lymph  circulation,  by  Avay  of 
rents  after  operation,  abortions,  or  full-term  deliveries,  is  most  com- 
monly the  cause  of  the  mischief.  IMany  good  observers  would  go  so 
far  as  to  say  that  they  know  of  no  possibility  of  cellulitis  unless  some 
septic  virus  has  been  introduced  into  the  vagina,  and  been  absorbed 
through  some  abrasion  or  fissure  in  the  mucous  membrane  of  the  vagina, 
cervix,  or  uterus.  Certainly  such  indefinite  causes  as  catching  cold, 
exposure  to  chill,  strains,  and  the  like,  are  more  and  more  regarded 
with  suspicion ;  and  attention  is  concentrated  on  the  possibility  of  the 
introduction  of  micro-organisms  with  its  septic  consequences. 

As  regards  the  production  of  pelvic  peritonitis,  the  point  of  most 
interest  is  to  consider  how  frequently  the  disease  is  consequent  on  a 
pre-existing  salpingitis.  In  1893  Dr.  Cullingworth  published  his  re- 
searches into  this  question.  Under  the  heading  of  "  Pelvic  Inflamma- 
tion usually  a  Peritonitis  originating  in  Salpingitis,"  he  says :  '•  The 
usual  state  of  things  disclosed  on  opening  the  abdomen  in  these  cases 
is  as  follows  :  — 

"The  contents  of  the  pelvis  are  generally  concealed  from  view  by 
the  great  omentum,  which  has  been  drawn  down  so  as  to  cover  them 
anteriorly,  and  has  contracted  adhesions  to  the  peritoneum  as  it  becomes 
reflected  on  to  the  anterior  abdominal  wail,  as  well  as  to  the  uterus  and 
other  pelvic  viscera.  Along  with  this  screen,  as  it  were,  of  omentum, 
it  is  not  unusual  to  find  coils  of  adherent  small  intestine.  On  separat- 
ing and  drawing  aside  the  screen,  one  side,  or  it  may  be  the  whole  of 
the  posterior  part  of  the  true  pelvis,  is  seen  to  be  occupied  by  what 
seems  to  ])e  an  indistinguishable  mass  of  matted  viscera.  The  uterus 
itself  is  sometimes  implicated  in  the  mass,  but  in  other  cases  its  upper 
part  at  least  is  free.  Tracing  the  Fallopian  tube  outwards  from  the 
uterine  corner  on  the  side  of  the  disease,  it  is  often  found  to  be  normal 
in  size  for  the  first  half  inch  or  so,  and  then  to  become  involved  in  the 
adherent  mass.  This  mass,  on  being  separated  and  brought  into  view,  is 
invariably  found  to  consist  of  the  uterine  appendages  more  or  less  altered 
Ijy  inflammation.  There  is  always  sal[)ingitis,  and  the  inflamed  and  thick- 
ened tube  commonly  enfolds  the  ovary,  which  is  frequently  normal." 

With  regard  to  tlie  tubes  the  first  point  to  be  noted  is  that  the 
evidences  of  peritoneal  inllanniiation  are  always  most  marked  in  the 
neighVjourhood  of  the  fimbriated  end;  this  shows  clearly  that  the  pelvic 
peritonitis  has  originated  by  direct  extension  from  the  mouth  of  the 
inflamed  tube,  or  by  the  escape  of  morbid  secretions  therefrom.  Where 
tlie  secretion  from  the  inflamed  tube  is  chiefly  mucous  in  character,  with 
only  a  slight  intermixture  of  jjus  corpuscles,  the  intensity  of  the  inflam- 


THE   DEVELOPMENT   OF  MODERN  GYNECOLOGY  25 

niation  round  the  abdominal  ostium  is  shown  by  the  extreme  density  of 
the  adhesions  at  that  spot  and  nothing  more.  ^Vhe^e  the  secretion,  on 
the  other  hand,  is  wholly  purulent,  one  of  two  things  is  found  to  have 
happened  according  to  whether  the  fimbriated  extremity  remains  patu- 
lous or  has  become  closed.  In  the  former  case  an  intraperitoneal  abscess 
is  found,  encysted  among  adhesions,  and  fed  by  the  purulent  discharge 
issuing  from  the  open  mouth  of  the  suppurating  tube  ;  in  the  latter 
case  the  pus  by  its  accumulation  distends  the  occluded  tube  and  forms  a 
pyosalpinx.  Mr.  Alban  Doran,  in  his  address  before  the  East  Anglian 
Branch  of  the  British  Medical  Association  in  1893,  shows  that  tubercu- 
lous disease  commencing  in  the  ovaries  and  tubes  may  spread  oiitward 
and  involve  the  peritoneum,  setting  up  tuberculous  pelvic  peritonitis. 
In  one  case  under  my  own  care  this  was  very  well  shown.  On  opening 
the  abdomen  of  a  young  woman  the  left  ovary  and  tube  Avere  found 
matted  together,  and  studded  with  small  masses  of  tuberculous  material : 
the  peritoneum  as  a  whole  was  healthy ;  but  in  the  immediate  neigh- 
bourhood of  the  diseased  tube  and  ovary  it  was  infected,  and  showed 
similar  foci  of  tuberculous  disease,  —  in  other  words,  a  localised  pelvic 
peritonitis  had  been  set  up.  It  is  clear,  then,  that  in  a  large  number 
of  cases  the  peritonitis  is  due  to  some  mischief  originating  in  the  ovary 
or  tube ;  but  neither  clinical  nor  post-mortem  evidence  has  yet  brought 
us  to  believe  that  the  disease  is  always  secondary  to  some  pre-existing 
morbid  condition  of  the  uterine  appendages. 

A.  form  of  pelvic  peritonitis  has  been  described  by  INIatthews 
Duncan  and  others  under  the  name  of  "encysted  serous  perimetritis." 
The  peculiar  feature  is  that  one  or  several  collections  of  serous  or  sero- 
purulcnt  fluid  are  found  pent  up  among  coils  of  intestines.  The  collec- 
tion may  occupy  the  pouch  of  Douglas,  and  press  the  floor  of  the 
pouch  so  forcibly  downwards  that  the  perineum  is  bulged.  In  many 
cases  of  pelvic  peritonitis  small  collections  of  serous  fluid  are  found 
pent  up  by  adhesions  between  the  coils  of  intestines  ;  but  the  disease  is 
seldom  specially  described  as  serous  perimetritis  unless  the  amount  of 
fluid  pent  up  be  very  extensive.  Before  leaving  this  subject  attention 
must  be  called  to  the  extension  of  our  knowledge  regarding  pelvic 
abscess ;  from  what  has  been  already  noted,  it  is  clear  that  collections 
of  pus  in  the  pelvis  are  by  no  means  alwa3'S  due,  as  had  been  supposed, 
to  suppuration  of  the  pelvic  connective  tissue.  Operative  surgery  has 
done  much  to  increase  our  pathological  knowledge  in  this  respect:  and 
we  now  know  that  many  so-called  pelvic  abscesses  are  really  suppurating 
dermoid  ovarian  cysts  adherent  low  in  the  pelvis,  or  perhaps  tubes  filled 
with  pus;  or  they  may  be  suppurating  hematoceles,  or  extra-uterine 
gestation  sacs.  This  thought  brings  us  to  the  subject  of  treatment  in 
cases  of  pelvic  inflammation. 

With  a  more  exact  knowledge  of  the  morbid  anatomy  and  clinical 
history  of  these  cases  of  pelvic  inflammation  our  treatment  lias  under- 
gone considerable  modifications ;  and  to  a  large  extent  active  surgical 
interference  has  taken  the  place  of  a  treatment  purely  medical  and  pallia- 


26  SVSr£J/  OF  GYNECOLOGY 

tive.  Indeed,  as  has  been  already  pointed  out,  there  has  been  a  marked 
tendency  to  resort  to  the  nse  of  the  knife  in  an  undue  percentage  of 
cases ;  and-  often,  too,  in  an  early  stage  of  the  disease  before  time  and 
observation  have  shown  us  what  the  natural  powers  of  repair  are  capa- 
ble of  doing.  The  case  is  different  when  the  presence  of  pus  can  be 
demonstrated  with  a  fair  amount  of  certainty;  for,  as  an  eminent  surgeon 
has  well  said,  a  collection  of  pus  calls  for  the  same  treatment,  whether  it 
occur  in  the  mammary  gland  or  in  the  pelvis,  and  opening  of  the  abscess 
with  evacuation  of  the  pus  is  urgently  demanded  in  either  case. 

Disorders  of  Menstruation. — The  division  of  these  disorders  into 
three  groups,  namely,  amenorrhoea,  menorrhagia,  and  dysmenorrhoea,  is 
a  very  old  one  and  a  very  excellent  one.  In  the  last  fifty  years  our 
knowledge  of  menstruation  and  its  variations  has  undergone  consider- 
able development,  not  only  through  the  revelation  of  new  facts,  but  yet 
more  by  the  exclusion  of  much  that  was  purely  imaginary  and  false. 
Several  points  of  considerable  discussion  and  doubt  may  be  considered 
as  finally  settled.  Thus  that  menstrual  blood  does  not  coagulate  is 
known  now  to  depend  on  a  certain  admixture  of  mucoid  secretion  from 
the  cervix  and  uterus.  Provided  that  the  menstrual  blood  be  not  in 
excess,  and,  secondly,  that  a  certain  proportion  of  healthy  mucus 
be  secreted,  we  may  be  sure  that  the  blood  will  remain  fluid :  but  if 
an  excess  of  blood  be  poured  out  from  the  uterine  wall,  and  the  mucus 
be  therefore  relatively  deficient  in  amount;  or  if  the  mucus  secreted  be 
morbid  in  quality  or  positively  deficient  in  amount,  we  are  certain  to 
find  that  the  menstrual  blood  does  clot.  The  coagulation  which  occurs 
in  cases  of  bleeding  submucous  fibroids,  or  again  in  certain  forms  of 
endometritis,  illustrates  this  point. 

Another  point  which  has  received  considerable  attention  concerns 
the  histology  and  alterations  of  the  uterine  mucous  membrane  during 
menstruation.  Study  of  the  infantile  uterus  by  Williams  and  others 
has  shown  that  to  speak  of  the  layer  of  tissue  superficial  to  the  mus- 
cular filjres  as  the  muco;is  membrane  is  not  correct ;  for  the  human  foetal 
uterus  shows  a  distinct  submucous  layer  just  beneath  the  peritoneum, 
so  that  the  whole  of  the  tissue  is  internal  to  this  mucous  membrane. 
Nearly  the  whole  of  the  muscular  thickness  of  the  human  uterus  is 
therefore  "muscularis  mucosae,"  and  the  apparent  absence  of  a  sub- 
mucous coat  is  thus  accounted  for. 

Another  interesting  question,  which  has  been  discussed  lately,  and  on 
which  much  light  has  been  thrown,  is  that  of  the  rhythmical  contractions 
of  the  uterus  which  occur  during  menstruation.  Viewing  menstruation 
as  a  miniature  labour,  one  would  expect  that  rhythmical  contractions, 
akin  to  the  recurring  pains  of  parturition,  would  be  set  up  at  the  men- 
strual epocl) ;  and  some  years  ago  Braxton  llicks  and  others  stated  their 
belief  tliat  these  contractions  occur.  Clear  evidence  of  the  fact  is  af- 
fordcfl  by  the  behaviour  of  a  uterus  which  contains  a  fibroid  polypus; 
for  with  the  onset  of  the  catamenia  the  internal  os  is  dilated,  the  cervi- 
cal canal  becomes  patulous,  and  the  external  os  is  enlarged,  so  that  the 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY  27 

finger  cau  be  introduced  and  the  tumour  felt.  As  the  menstrual  period 
passes  the  canal  closes  down  again,  and  the  internal  os  becomes  closed. 
Again,  if  the  cervical  canal  be  tested  by  the  passage  of  graduated 
bougies  before  and  during  the  first  few  days  of  menstruation,  the  same 
opening  of  the  cervical  canal  by  the  force  of  the  uterine  contractions 
can  be  observed.  Sir  John  AVilliams  has  stated  that  the  uterus  contracts 
during  menstruation,  because  the  cavity  after  menstruation  is  smaller 
than  it  would  be  if  the  mucous  membrane  were  gone  without  uterine 
contractions.  The  importance  of  the  recognition  of  this  fact  will  be 
seen  when  w^e  come  to  study  the  causation  of  pain  in  connection  Avith 
menstruation.  In  speaking  of  the  changes  which  occur  in  the  mucous 
membrane  of  the  uterus  at  and  about  the  menstrual  epoch,  it  cannot  be 
said  that  our  knowledge  has  made  much  advance ;  there  are  many 
opinions  on  the  subject,  but  little  definite  knowledge.  JNIodern  research 
has  made  one  point  fairly  certain,  namely,  that  the  whole  of  the  mucous 
membrane  of  the  uterus  is  not  shed  every  month ;  but  rather  that 
certain  changes  of  a  hypertrophic  and  fatty  degeneration  occur  which 
lead  to  the  exfoliation  of  the  superficial  part  of  this  membrane.  The 
papers  bearing  on  this  subject  by  Kundrat  and  Engelmann,  Leopold, 
Williams,  Wyder,  and  others,  are  too  well  known  to  call  for  farther 
comment. 

Amenorrhoea.  —  No  great  advance  has  been  made  in  our  knowledge  or 
treatment  of  amenorrhoea.  In  cases  of  imperforate  h^nnen  common  sense 
has  taught  us  that  repeated  aspirations  are  quite  unnecessary,  and  that 
free  incision  of  the  hymen  under  antiseptic  precautions,  followed  by  rapid 
evacuation  of  the  retained  menstrual  fluid,  is  a  safe  and  scientific  mode 
of  treatment.  If  the  opening  made  in  the  hymeneal  membrane  be  free 
and  patulous,  there  is  little  risk  of  fluid  regurgitating  down  the  Fallopian 
tubes,  even  though  these  latter  be  somewhat  dilated.  Under  modern 
antiseptic  precautions  one  never  sees  the  rapidly  fatal  instances  of  septic 
peritonitis  which  used  every  now  and  again  to  terminate  these  cases.  In 
the  production  of  healthy  menstruation,  it  is  recognised  that  a  healthy 
anatomical  tract  from  the  ovary  to  the  hymen,  a  healthy  condition  of  the 
blood,  and  a  sound  state  of  the  nervous  system  are  required ;  so  in  con- 
sidering the  causation  of  amenorrhoea  (if  Ave  exclude  pregnane}-,  lactation, 
delayed  onset,  and  the  menopause),  it  is  clear  that  all  cases  must  come 
under  one  of  these  headings. 

In  his  lecture  on  sterility,  Matthews  Duncan  drew  attention  to 
an  interesting  condition  of  Avhat  he  termed  -'one-child  sterility."  In 
these  cases  a  healthy  but  delicate  young  Avoman,  usually  of  the  upper 
classes,  marries  and  begets  one  child,  and  after  this  confinement  men- 
struation never  returns,  the  uterus  passes  into  a  senile  state,  and  the 
Avoman's  reproductive  life  is  practically  over.  Here  the  absence  of  the 
menstrual  function  depends  on  a  premature  exhaustion  of  the  genital 
system,  and  on  an  early  exhaustion  of  the  ovary  with  its  Graafian  follicle 
system. 

Menorrhagia.  —  Improved  methods  of  dilatation,  and  the  safety  which 


28  SYSTEM  OF  GYNAECOLOGY 

comes  from  the  use  of  antiseptics,  have  done  miich  to  enlighten  ns  on  the 
causation  and  treatment  of  uterine  haemorrhage.  Thus  twenty  years  ago 
comparatively  nothing  was  knowTi  of  the  existence  and  frequency  of 
fungous  degeneration  of  the  endometrium ;  whereas  now  the  use  of  the 
curette  and  digital  exploration  of  the  uterine  cavity  have  shown  us  its 
frequency  in  cases  of  endometritis  and  fibroid  tumour.  Of  late  3^ears  the 
pathological  changes  taking  place  in  fi_broid  tumours  have  been  worked 
out ;  their  methods  of  cure  by  natural  processes  have  been  clearly  laid 
down,  and  many  points  in  their  treatment  have  been  carefully  studied. 
Reference  has  already  been  made  to  the  so-called  Apostoli  treatment ; 
and  whatever  the  measure  of  its  failure  in  the  cure  of  fibromyoma,  there 
can  be  no  doubt  that  in  the  menorrhagia  depending  on  the  presence  of 
a  submucous  fibroid,  this  method  is  a  useful  addition  to  our  remedies. 

Attention  has  been  paid  in  late  years  to  the  influence  of  an  obstructed 
circulation  in  the  production  of  uterine  haemorrhage.  Thus  the  late  Dr. 
Wiltshire  pointed  out  the  effects  of  the  early  stages  of  liepatic  cirrhosis, 
consequent  upon  the  abuse  of  alcohol,  in  keeping  up  uterine  blood  loss ; 
here  the  effect  of  an  impeded  portal  circulation  in  preventing  easy  escape 
of  blood  from  the  uterine  circulation  is  well  demonstrated,  for  by  cutting 
off  the  supply  of  alcohol,  and  exhibiting  remedies  which  act  favourably 
on  the  portal  circulation,  the  menorrhagia  can  soon  be  controlled. 

Again,  in  the  case  of  an  overloaded  right  heart,  due  to  valvular  or 
to  pulmonary  disease,  another  mode  of  production  of  menorrhagia  has 
been  shown ;  for  by  the  use  of  means  calculated  to  assist  the  heart's 
action  the  uterine  disorder  is  materially  relieved  and  finally  cured.  In 
the  knowledge,  moreover,  of  such  drugs  as  hamamelis  and  the  hydrastis 
Canadensis,  we  have  made  valuable  additions  to  our  store  of  uterine 
styptics. 

Dysmenorrhea.  —  It  is  a  cause  for  regret  that  we  have  made  so  little 
advance  in  our  knowledge  of  this  common  disorder  ;  still  in  some  respects 
we  may  claim  to  have  gained  a  more  exact  and  scientific  acquaintance 
with  the  Y^henomena  of  painful  menstruation.  Dr.  Champneys  has  en- 
deavoured to  limit  the  use  of  the  Avord  pain  as  applied  to  dysmenorrhoea, 
and  has  suggested  that  it  is  only  correctly  used  when  the  suffering  is 
clearly  due  to  the  genital  organs,  and  falls  withiii  the  genital  sphere. 
Pain  due  to  the  pelvic  organs  is  limited  above  by  a  line  level  with  the 
iliac  crests  in  front  and  behind,  and  by  the  level  of  the  knees  below ;  by 
this  definition  various  neuralgias,  which  are  often  present  during  the 
menstrual  epoch,  are  excluded.  Tyler  Smith  and  other  authorities  have 
comyjared  the  act  of  menstruation  to  a  miniature  pregnancy ;  and  I  my- 
self, following  out  this  simile,  have  shown  that  in  a  large  ])roportion  of 
cases  the  pain  of  dysmenoiThaia  is  due  to  some  morV)id  conditicm  at  the 
OS  internum,  and  that  tlie  ])ain  really  depends  on  dilatation  of  the  in- 
ternal OS  l)y  uterine  contractions  under  morbid  conditions. 

Reference  has  already  been  made  to  the  fact,  that  uterine  contractions 
are  present  during  menstruation,  and  that  their  effect  in  dilating  the 
cervical  canal  is  capable  of  clinical  proof. 


THE  DEVELOPMENT   OF  MODERN  GYNECOLOGY  29 

One  form  of  dysmenorrhoBa,  distinguished  by  tlie  exfoliation  of  a 
membrane  every  month,  has  received  special  attention  from  gynecolo- 
gists ;  indeed,  the  literature  of  the  subject  is  so  extensive,  that  Avere  its 
value  equalled  by  its  bulk,  our  knowledge  of  the  subject  would  indeed 
be  complete.  Much  difference  of  opinion  has  been  expressed  on  the  eti- 
ology and  pathology  of  these  membranes ;  but  the  researches  of  Wyder 
and  others  seem  to  point  to  inflammation  as  their  cause.  The  thickness 
of  the  membrane,  and  the  depth  of  the  mucous  membrane  exfoliated, 
vary  greatly ;  and  the  microscopical  examination  shows  a  great  variety 
of  pathological  conditions :  all  these  conditions,  however,  are  "  endome- 
tritic."  Wyder  has  remarked  upon  the  presence  of  certain  large  oval 
cells,  which  have  a  length  of  from  0-012  to  0-02  mm.,  and  nuclei,  whose 
diameter  is  0-006 ;  or  these  cells,  he  says,  may  be  two  or  three  times  as 
large.  These  large  cells,  he  believes,  are  found  only  in  the  decidua  of 
pregnancy,  either  intra  or  extra-uterine ;  and  they  serve,  therefore,  to 
distinguish  real  membranous  dysmenorrhoea  from  early  abortions. 

It  has  been  pointed  out  that  it  is  necessary  to  distinguish  the  triie 
membrane  of  membranous  dysmenorrhoea  from  those  consisting  of  fibrin 
or  blood-clot,  coagulated  mucus,  casts  of  the  vagina  or  the  bladder, 
foreign  bodies,  or  products  of  conception.  It  has  been  shown  by  many 
writers  that  mucosa  membranes  may  be  passed  for  some  time  without 
the  presence  of  any  pain ;  and  pain  may  be  a  marked  symptom  later. 
Thus  it  is  suggested  that,  apart  from  some  special  sensitiveness  of 
the  canal  of  the  uterus,  pain  need  not  result  from  the  separation  and 
passage  of  the  membrane.  How  unsatisfactory  is  our  treatment  of 
membranous  dysmenorrhoea  may  be  inferred  from  a  remark  which 
Champneys  makes  use  of  in  his  Harveian  Lectures.  "  The  treatment 
of  membranous  dysmenorrhcsa  certainly  is  a  most  unhappy  problem : 
not  even  pregnancy  going  to  full  time  cures  it." 

There  is  another  pathological  condition  in  which  gynaecology  has 
made  marked  progress  during  the  last  fifty  years,  namely,  inversio  uteri. 
Until  the  year  1858,  cases  of  inversion  of  the  uterus  after  lal)0ur  were 
only  cured  when  the  patient  came  under  observation  shortly  after  par- 
turition ;  and  in  too  many  cases  amputation  of  the  inverted  organ  was 
considered  the  only  available  resource.  About  this  date  Tyler  Smith  in 
England,  and  White  in  America,  recorded  cases  of  slow  reduction  by  taxis 
and  elastic  pressure.  Of  late  years  cures  have  been  so  numerous,  even 
in  cases  which  have  come  under  treatment  several  years  after  the  acci- 
dent had  happened,  that  the  various  instances  are  hardly  thought  worthy 
of  record.  The  method  of  reduction  which  is  in  favour  at  present  con- 
sists in  the  use  of  Aveling's  repositor.  The  latter  instrument  was  in 
no  sense  invented  by  Dr.  Aveling,  for  Von  Siebold  employed  a  reposi- 
tor which  consisted  of  a  curved  stem  surmounted  by  a  fine  sponge,  the 
whole  being  lield  in  position  by  a  T  bandage.  ]\Iost  of  these  earlier 
instruments,  however,  having  only  one  curve  on  their  stem,  were  liable 
to  slip;  whereas  in  Aveling's  repositor  there  is  a  double  curve  (both 
sacral  and  perineal"!,  pressure  is  transmitted  in  the  curve  of  the  pelvic 


SYSTEM  OF  GYNECOLOGY 


axis,  and  slipping  is  thns  rendered  less  probable.  Of  tlie  many  other 
plans  devised  for  procuring  slow  reduction  of  a  clironically  inverted 
uterus,  few -have  stood  the  test  of  time;  and  year  by  year  the  Aveling 
repositor  becomes  increasingly  popular  in  the  cure  of  these  difficult  and 
dangerous  cases.  In  a  few  cases  the  accident  does  not  follow  labour, 
but  depends  on  the  presence  of  a  fibroid  or  polypus  growing  from  the 
fundus  uteri ;  it  is  in  these  latter  cases  that  vaginal  amputation  of  the 
mass,  without  any  attempt  at  reduction,  is  indicated. 

In  the  short  space  available  it  has  been  impossible  to  trace  at  all 
adequately,  or  to  do  justice  to  ranch  which  may  be  reckoned  as  devel- 
opment of  our  science  and  practice ;  but  enough  has  been  reviewed  to 
show  that  in  every  department  of  gynaecology  —  in  pathology,  in  bacte- 
riology, in  anatomy,  clinical  medicine,  and  surgery  —  marked  progress 
has  been  made;  and  if  at  times  advance  has  been  retarded  by  over-zeal- 
ous enthusiasts,  still  even  to  them  we  are  perhaps  indebted  for  the  fin- 
ger-posts which  point  out  the  roads  on  which  we  should  not  travel.  It  is 
clear  that  much  of  our  increased  knowledge  is  due  to  improved  surgery, 
and  to  say  this  is  again  to  declare  the  debt  we  owe  to  Sir  Joseph  Lister. 

Mr.  Pearce  Gould  put  the  matter  very  eloquently  when,  in  his  recent 
address  on  the  Evolution  of  Surgery,  he  said :  "  Although  science  knows 
nothing  of  nationality,  and  we  rejoice  in  additions  to  our  knowledge,  and 
to  our  powers  of  combating  disease  and  death,  whether  it  comes  to  us 
from  a  French  Pasteur,  from  a  Teuton  Koch,  from  our  western  cousins 
on  the  other  side  of  the  broad  Atlantic,  or  from  a  son  of  that  Eastern 
Empire  now  rising  above  the  horizon,  we  cannot  help  feeling  a  special 
pride  in  the  fact,  that  the  name  that  shines  Avith  an  unrivalled  splen- 
dour on  the  jjage  of  surgical  history  is  that  of  the  Englishman  Joseph 
Lister." 

Montagu  Handfield- Jones. 


REFERENCES 

1.  Atlee.  Ovarian  Tumours. — 2.  Battey.  Gynmcol.  Trans.  187G.  —  3.  Henry 
Bennet.  Inflammation  of  the  Uterus,  1845. — 4.  Bbunutz  and  Goupil.  Archiv  Gdn. 
1857.  —  5.  Billroth.  Surgical  Pathology.  —  (].  Bourdon.  Fiuctuatinfj  Tumour  of  True 
Pelvis,  \V4\. — 7.  Burns.  Midwifery.  —  8.  Calvi.  Jutrapelvic  Phlegmonous  Abscess, 
1844. — 9.  Churchill.  Abscess  of  Uterine  Appendages,  1844.  — 10.  (Jlark.  Diseases 
of  Females.  — 11.  Clay.  Obstetric  Surgery .  — 12.  Cullingworth.  Brit.  Med., Jour.  yo\. 
ii.  180:}.  —  l.'i.  Dicnman.  Midwifery.  — 14.  Doherty.  Chronic  Inflammation  of  the 
Uterine  Appendugrs,  184.'i.  — 1.5.  Alban  Doran.  Address  Brit.  Med.  Assoc.  Brit.  Med. 
Jour.  OcA.  \8'.y.i.  — 10.  Ibid.  Uterine  Surgery .  — 17.  Matthews  Duncan.  Lond.  Obstet. 
Soc.  \o\.xx\n.  — 18.  Ibid.  l'aram,etritis  and  Perimetritis. — li).  Ibid.  Fecundity,  Fe?-- 
tiUty,and  Sterility.— 20.  Handfield-Jonks.  Brit.  Med.  Jour.  W.)3.  —  21.  Hart  and 
Barik^ur.  Diseases  of  Women. — 22.  Hkqar  and  Kaltionhach.  Op.  Gyn.  —  21?. 
<ii;Air-v  IIkwitt.  Diseases  of  Women.  — '14.  Hoixik.  JHscases  I'ecullar  to  Women. — 
'!').  Kki'ih.  Tumours  of  Abdomen.  —  20.  Kundhat  and  En(JKLMANn.  Strieker's 
Med.  Jahrbueh..  187.").  —  27.  Leukrt.  Traits  des  Mai.  Vancereuses.  —  28.  Leopolu. 
Ai-cli.  fur  Gyndk.  Band  xi.  1877,  Band  xxi.  1883.  — 29.  Lever.  Pelvic  Abscess, 
1>J44. — ;jo.  Nonat.  Maladies  de  I'Utdrus.  —  31.  Paoet.  Surgical  Pathology.  —  .32. 
Priestley.    B.  M.  J.  vol.  ii.  1895.  — .33.  Simh.     Uterine  Surgery.  —  34.   Stephenson. 


THE  ANATOMY   OF  THE  FEMALE  PELVIC   ORGANS  31 

B.  M.  J.  March  1892.  — 35.  Sutton,  Bland.  Roy.  Med.-Qhir.  Tranmct.  1889.— 
36.  Ibid.  Lond.  Med.  Soc.  1892.  — 37.  Tait,  Lawson.  Disaases  of  Women.  —  38. 
Thomas.  Diseases  of  Women.  —  .39.  Thornton,  J.  K.  "  Abdoiuiiial  Surj^ery  Past  and 
Present,"  Lond.  Med.  Soc.  Transact.  1890. —40.  Tilt.  Ovarian  Infunimatlon,  1850. 
—  il.  Ibid.  Uterine  Therapeutics.  —  42.  Velpeau.  Operative  Suryer;/. — 43.  Virchow. 
Cellular  Fatho logy. — 44.  Spencer  Wells.  Abdominal  Tumoin-s. — 45.  Williams. 
Harveian  Lectures,  1888.-46.  Ibid.  Obst.  Soc.  Lond.  —  il.  Wyder.  Arch.  f.  Gyn. 
Band  xiii.  1878. 

M.  H.-J. 


THE  ANATOMY   OF   THE   FEMALE   PELVIC   ORGAKS 

A  DESCRIPTION  of  the  anatomy  of  the  genital  organs,  for  gynecological 
purposes,  should  have  its  own  topographical  basis ;  that  is,  it  should  be 
described  in  relation  to  the  bony  pelvis. 

I  shall  therefore  arrange  this  subject  under  the  following  heads:  — 
I.    The  main  points  in  the  anatomy  of  the  adult  female  bony  pelvis 
and  of  the  p)elviG  floor  filling  in  the  'pelvic  outlet. 
II.    Tlie  anatomy  of  jpcirt  of  the  outer  aspect  of  the  floor  —  that  is,  of 
the  vulva  or  external  genitals. 

III.  The  anatomy  of  the  organs  and  tissues  in  the  substance  of  the  pelvic 

floor — that  is,  of  the  vagina,  urethra,  and  bladder;  rectum  and 
anus;  connective  tissue,  blood-vessels,  lymp)hatics,  and  nerves. 

IV.  The  anatomy  of  the  organs  on  the  upper  aspect  of  the  pelvic  floor 

—  that  is,  of  the  litems,  Fcdlopian  tubes,  broad  ligaments,  and 
ovaries ;  the  loelvic  jyeritoneum. 
V.    The  position  of  the  organs :  their  dissection  and  structural  an  atomy. 
VI.    The  surgiccd  anatomy. 

VII.    The  development  of  the  organs. 

This  convenient  method  of  considering  our  subject  is  open  to  some 
objections.  It  might  be  argued,  for  instance,  that  the  anus  and  urethra 
could  be  considered  in  other  divisions  than  those  in  which  I  have  placed 
them.  The  present  arrangement,  however,  will  be  found  suitable  for 
our  purpose. 

I.  The  main  points  in  the  anatomy  of  the  Female  Bony  Pelvis  and  of  the 
Pelvic  Floor  filling  in  the  outlet.  —  The  brim  of  the  pelvis  (Fig.  1)  has, 
as  its  boundaries,  from  left  to  right,  the  promontory,  left  sacro-iliac 
joint,  left  ilio-pectineal  eminence,  symphysis  pubis,  right  ilio-pectineal 
eminence,  right  sacro-iliac  joint,  and  thus  back  to  the  promontory. 

The  part  of  the  pelvis  above  the  brim  is  termed  tlie  "false ''  jjclvis; 
that  below  the  brim  is  spoken  of  as  the  "  true  "  pelvis.  It  is  in  the 
true  pelvis  and  in  relation  to  the  outlet  that  the  unimpregnated  female 
genital  organs  are  placed. 

If  the  bony  pelvis  be  regarded  in  sagittal  mesial  section  (Fig.  2), 
we  can  see  the  conjugate ;  the  cavity-  of  the  true  pelvis,  with  its  inlet, 


32 


SYSTEM  OF  GYNECOLOGY 


cavity,  and   outlet ;    the   inclination  of   the  conjugate  to  the  horizon 
(average  of  60''),  as  well  as  the  outline  of  the  pelvic  floor.     What  of  the 


Fig.  1.  —  Brim  of  bony  pelvis. 


pelvic  floor  projects  beyond  the  outlet-conjugate  is  termed  the  pelvic 
floor  projection,  and  averages,  at  its  utmost,  about  3-2  cm. 


Fio.  2.  — I>lii(,'ram  of  bony  pelvis  and  of  pftlvio  floor.    1,  Conjupato ;  2,  anal  axis;  3,  4,  va^nal  and 
urethral  axes;  6,  horizontal  line;  G,  oiitlot-conjugate. 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS 


Zl 


On  the  outer  aspect  of  the  pelvic  floor  lie  the  external  genitals,  and 
these  in  the  upright  posture  have  a  direction  nearly  parallel  to  the 
horizon. 

Tn  the  substance  of  the  pelvic  floor  lie  the  vagina  and  urethra,  parallel 
to  the  conjugate,  and  about  2;V  to  3  inches  below  its  level ;  the  anus  with 


FALLOPIAN  TU- 


AN  riMSRIA 


POUCH  OF  DOUGLAS 


ANUS 
PERINEAL  BODY 


//  BETROPUarO 


LABIUM  MINUS 


Fig.  3.  — Sagittal  mesial  section  of  female  pelvic  floor.     The  ovary  is  larger  than  normal,  and  the  tube 

relations  not  quite  normal. 

its  long  axis  at  right  angles  to  these ;  and  resting  on  the  upper  surface, 
the  peritoneum  and  the  uterus  with  its  appendages  (Fig.  3).  Dr.  Her- 
man gives  the  following  table  of  clinical  measurements :  — 


Projection  of  pelvic  floor 

Coccyx  to  anus 

Fourchette  to  pubic  arch  (nulliparse 


3-2  cm. 

4o  cm. 
2- in  cm. 


II.  The  anatomy  of  the  External  Genitals  —  that  is.  of  part  of  the 
outer  aspect  of  the  pelvic  floor. — The  external  genitals  lie  on  a  surface 
extending  from  the  front  of  the  symphysis  pubis  downwards  and  back- 

j> 


34 


SYSTEM  OF  GYNAECOLOGY 


wards  between  the  thighs,  their  posterior  boundary,  the  fourchette,  being 
about  1-1  Jf  inch  in  front  of  the  anus.  They  comprise  the  following 
structures  ;  -nanieh^,  the  labia  niajora,  labia  minora,  fourchette,  clitoris 
and  prepuce,  vestibule,  urethral  orifice,  hymen,  fossa  navicularis. 
The  general  arrangement  of  these  parts  is  seen  in  Figs.  2  and  4. 
It  must  be  noted  that  in  order  to  see  these  parts  in  the  living  woman 
their  mutual  relations  are  necessarily  disturbed.  It  is  therefore  of  im- 
portance to  note  that,  in  the  undisturbed  condition,  the  labia  majora 
and  minora,  being  in  contact  by  their  inner  surfaces,  conceal  the  deeper 
structures,  the  minora  only  projecting  slightly  beyond  the  majora;  that 
probably  the  lateral  halves  of  the  vestibule  are  in  apposition ;  that  tiie 
lateral  edges  of  the  fourchette  touch,  forming  a  long  U,  as  seen  in  Fig.  4; 
and  that  the  lateral  edges  of  the  hymen  are  also  in  contact. 

The  labia  majora  are  two  folds  of  skin,  united  above  over  the  pubes  in 
the  mons  veneris,  which  pass  downwards  and  backwards  between  the 
thighs,  gradually  thinning  off  at  a  point  li  inch  in  front  of  the  anus. 
Short  crisp  hair  covers  their  outer  aspect,  and  microscopically  we  find 
sweat  glands,  hair  follicles,  and  the  usual  constituents  of  a  skin  structure. 
The  labia  minora  are  also  formed  of  skin  of  a  thin,  fine  quality ; 
they  lie  obliquely  on  the  inner  aspect  of  the  upper  two-thirds  of  the 
labia  majora,  and  by  the  bifurcation  of  their  upper  ends  form  the  pre- 
puce of  the  clitoris  and  its  so-called  suspensory  ligament. 

The  vestibule  is  a  triangular 
surface  of  smooth  mucous  mem- 
brane covered  with  several  layers 
of  epithelium,  lying  between 
the  labia  minora,  and  having 
the  hymen  at  its  base;  the  ure- 
thral orifice  is  in  the  middle 
of  the  base  line  immediately 
above  the  hymen.  In  the  mid- 
dle line,  in  the  virgin,  is  a 
grooved  ridge  which  represents 
the  corpus  spongiosum  of  the 
male  —  Pozzi's  male  vestibular 
band. 

The  posterior  ends  of  the 
labia  minora  form  a  narrow  U- 
shaped  loop  —  the  fourchette ; 
if  these  margins  be  separated 
we  see  the  fossa  navicularis 
as  a  shallow  fossa,  artificially 
made  by  the  examination,  and 
bounded  by  the  inner  aspects 
of  the  fourchette  and  outer 
and  lower  portions  of  the 
uid  base  of  the  vestibule  lies  the 


LABIUM  MAJUS 
PREPUCE 
CLANS  CLITORIDIS 
1_ABIUM   MINUS 


FOURCHETTE 


Fig.  4. 


-  Viixin  external  (feniUils  willJ  the 
labia  majora  separated. 


hvmen.       I'etwefn   1lift   rourc,liC'ttc 


THE   ANATOAIY   OF   THE   FEMALE   PELVIC   ORGANS 


35 


hymen,  the  anatomical  entrance  to  the  vagina.  It  consists  of  a  thin  fohl 
of  mucous  membrane,  perforated,  so  that  when  viewed  undisturbed,  its 
opening  forms  a  vertical  slit  with  its  edges  in  contact.  According  to  Dr. 
Cullingworth,  the  hymen  is  a  longitudinal  fold  of  mucous  membrane  with 
its  edge  directed  forwards,  and  divided  along  about  three-fourths  of 
its  length  by  a  slit  which  extends  nearer  its  upper  than  its  lower 
extremity.  The  alterations  in  it  induced  by  coitus  and  labour  belong 
to  obstetrics. 

The  anal  opening  lies  about  1\  inch  posterior  to  the  fourchette, 
and  between  the  two  is  the  skin  over  the  base  of  the  perineal  body 
(Fig.  4). 

The  glans  of  the  clitoris  covered  by  its  prepuce  lies  at  the  apex  of 
the  vestibule. 

III.  The  anatomy  of  the  organs  and  tissues  in  the  substance  of 
the  pelvic  floor  —  that  is,  of  the  Vagina,  Urethra,  Bladder,  Rectum, 
and  Anus,  Connective  Tissue,  Blood-Vessels,  Lymphatics,  and  Nerves. 
—  Ilie  vagina  is  a  transverse  slit  in  the  pelvic  floor,  extending  from  the 
hymen  to  the  fornices,  where  it  passes  on  to  the  outer  aspect  of  the 
vaginal  portion  of  the  cervix  uteri  at  the  base  of  the  latter ;  the  de- 
marcation between  them  being  recognisable  to  the  naked  eye. 

The  vagina  lies  parallel  to  the  conjugate,  and  consists  of  two  apposed 
walls,  anterior  and  posterior.  Each  wall  is  broader  above  than  below, 
and  is  therefore  somewhat  triangular  in  shape.  The  mucous  membrane 
lining  it  is  thrown  into  many  transverse  shallow  folds  — the  rugai  of  the 
vagina.  At  the  lower  end  of  the  posterior  Avail  is  one  short  vertical  fold, 
the  posterior  column  of  the  vagina ;  while  there  are  usually  two  at  the 
corresponding  portion  of  the  anterior  wall  —  the  anterior  columns  of  the 
vagina.  They  are  said  to  represent  the  remains  of  the  septa  between 
the  two  ducts  of  Miiller,  from  part  of  which  the  vagina  is  formed 
(Fig.  3). 

Between  the  vaginal  portions  of  the  cervix  and  the  reflexions  of 
the  vaginal  walls  lie  the  fornices  of  the  vagina  —  anterior,  lateral,  and 
posterior.  The  anterior  is  the  guide  to  the  loose  tissue  between  the  bladder 
and  the  cervix;  the  lateral  lie  at  the  inner  aspects  of  the  bases  of  the  broad 
ligaments,  and  form  a  guide  to  the  uterine  artery  and  ureter ;  while  the 
posterior  is  separated  from  the  peritoneum  of  the  pouch  of  Douglas  by 
about  ^  inch  of  tissue.     The  walls  of  the  fornices  are  in  contact. 

On  sagittal  mesial  section  (Fig.  3)  the  anterior  wall,  2.V  inches  long, 
is  seen  to  be  straight;  the  posterior  wall,  3.V  inches  long,  bends  forward 
at  its  upper  part. 

On  transverse  section  the  vagina  is  crescentic  at  its  upper  part, 
H-shaped  lower  down,  and  vertical  at  the  hymen. 

Microscopically  the  hymen  has  multiple  epithelium  on  its  outer  and 
inner  aspects,  the  latter  being  thicker. 

The  vagina  is  lined  on  its  free  surface  by  many  layers  of  squamous 
epithelium  ;  deeper  down  near  the  papilhp,  the  epithelium  is  more  oval  in 
shape.     Tliis  epitlu^liuni  lies  on  papillas  of  connective  tissue,  with  elastic 


SYSTEM   OF  GYNAECOLOGY 


tissue  and  iinstiiped  muscular  fibre.  Outside  this  lie  two  layers  of 
unstriped  muscular  fibre,  an  outer  (circular)  and  inner  (longitudinal). 
Only  a  few  glands  are  present  in  the  vagina,  which  has  a  structure  quite 
homologous  to  skin. 

It  is  of  great  importance  to  note  that  loose  connective  tissue  separates 
the  anterior  rectal  wall  and  the  posterior  vaginal  wall,  and  lies  also 
between  the  bladder  wall  and  the  anterior  vaginal  wall.  The  urethra 
and  anterior  vaginal  wall  are  closely  incorporated. 

The  urethra  forms  a  slit  in  the  pelvic  floor,  parallel  to  the  vagina,  and 
is  in  reality  a  tonically  contracted  sphincter  1|  inch  long  with  the  urethral 
orifice  below  and  the  bladder-opening  above.  It  is  lined  with  many 
layers  of  epithelium,  squamous  below,  and  like  that  of  the  bladder  above. 


Yagina 


Fio.  5.  —  Rectal  and  vaginal  mucous  membrane. 

It  is  well  provided  with  elastic  tissue  and  muscle ;  for  there  are  not  only 
circular  and  longitudinal  unstriped  fibres,  but  the  same  arrangement  of 
striped  muscle  also.  Finally,  Ave  should  keep  in  mind  that  at  the  meatus 
mucous  glands  are  present  as  well  as  villous  tufts.  Skene's  tubules  lie  at 
the  lower  end  of  the  floor  of  the  urethra,  are  two  in  number,  about  f  in. 
in  length.  A  very  important  practical  point  about  the  urethra  is  its 
dilatability.  By  means  of  suitable  dilators  an  amount  of  dilatation  can  be 
obtained  sufficient  to  admit  the  ordinary  index  finger.  Over-dilatation, 
however,  may  cause  permanent  incontinence. 

With  the  empty  bladder  the  urethra  forms  a  Y,  the  anterior  limb  of 
the  Y  Vjeing  the  longer.  Between  the  urethra,  anterior  surface  of  bladder, 
and  tlie  posterior  aspect  of  the  pubes  is  a  s])ace,  ti-iangular  in  shape  on 
section,  containing  loose  tissue  and  fat  —  the  retro-])ii))ic  fat  (Fig.  3). 
The  bladder  is  sometimes  seen  in  the  cadaver  as  a  thick-walled,  appar- 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS  37 

ently  contracted  organ,  with  its  anterior  and  posterior  walls  in  contact. 
On  sagittal  mesial  section  the  cavity  then  forms  a  slit  continuous  with 
the  urethra. 

The  bladder  walls  consist  of  mucous  membrane  lined  with  multiple 
and  multiform  layers  of  epithelium,  and  of  unstriped  muscle  in  three 
layers ;  its  fundus  alone  is  covered  by  peritoneum.  The  mucous  and 
muscular  coats  are  separated  by  loose  tissue.  The  empty  bladder  is  a 
pelvic  organ  in  the  non-pregnant  woman.  It  is  generally  believed  that 
its  capacity  is  greater  in  women  than  in  men ;  and,  as  a  matter  of 
fact,  many  women  pass  water  twice  only  in  the  twenty-four  hours. 

The  u7-eters,  two  in  number,  run  between  the  kidneys  and  the  bladder. 
I  shall  describe  their  course  in  the  pelvis  only.  At  the  pelvic  brim  each 
crosses  the  external  iliac  artery,  and  passes  down  the  side  wall  of  the 
pelvis  below  the  level  of  the  fossa  ovarii.  Where  the  vesical  and  obturator 
vessels  originate,  it  begins  to  describe  a  bow-shaped  curve,  the  middle  por- 
tion of  which  is  crossed  by  the  uterine  artery  at  the  level  of  the  os  uteri 
externum,  from  which  it  is  about  f  inch  distant.  It  here  lies  related  to 
the  side  of  the  vagina  (Figs.  8  and  19),  and  then  runs  between  the  anterior 
vaginal  wall  and  posterior  bladder  wall.  It  finally  runs  in  the  substance  of 
the  bladder  wall  for  about  0-6  inch,  and  opens  into  the  bladder  cavity. 

If  the  bladder  cavity  be  laid  open  we  shall  see  three  openings  into 
it ;  namely,  the  internal  orifice  of  the  bladder  in  the  middle,  and  a  ureteric 
opening  at  each  side.  The  latter  are  about  li-  inch  from  the  middle 
line.     Between  the  ureteric  ends  lies  the  inter-ureteric  ligament. 

The  rectum  begins  at  the  pelvic  brim,  and  ends  at  the  anus.  We 
recognise  three  portions ;  namely,  the  first  part,  provided  with  a  meso- 
rectum,  beginning  at  the  left  sacro-iliac  joint,  and  ending  at  the  third 
sacral  vertebra ;  the  second  part,  where  the  peritoneum  gradually  passes 
off  from  behind  towards  the  front ;  and  the  third  part  lying  behind  the 
posterior  vaginal  wall.  It  is  separated  from  the  posterior  vaginal  wall 
by  loose  tissue.  The  inicroscopical  structure  of  the  rectum  is  perito- 
neum outside ;  unstriped  muscular  fibre  in  two  layers  —  the  longitudinal 
inner,  and  the  circular  outer ;  and  a  submucous  coat  with  a  mucous  mem- 
brane provided  with  a  muscularis  niucosse.  The  mucous  membrane  is 
provided  with  abundant  Lieberkuhnian  follicles. 

There  are  two  important  crescentic  folds  in  the  rectum,  which  form 
the  sphincter  tertius  ;  they  lie,  one  on  the  anterior  wall,  the  other  on  the 
posterior.  Each  is  about  1,V  inch  from  the  anus,  the  posterior  being 
the  higher.  The  fold  is  formed  by  a  special  thickening  of  the  circular 
muscles. 

The  anus  is  a  closed  slit  in  the  pelvic  floor  with  only  a  slight  antero- 
posterior linear  measurement.  It  measures  about  an  inch  in  length,  and 
runs  parallel  to  the  axis  of  the  pelvic  brim;  that  is,  at  right  angles  to 
the  rectal,  vaginal,  and  urethral  axes  (Fig.  2).  It  is  provided  with  a 
strong  musculature  (Fig.  6);  namely,  the  sphincter  externus,  and  sphincter 
iuternus,  —  the  latter  in  two  layers,  circular  (outer)  and  longitudinal 
(Ruedinger). 


38 


SYSTEM  OF  GYNECOLOGY 


In  front  of  the  amis  lies  the  perineal  body,  its  apex  being  about  the 
level  of  the  internal  opening  of  the  anus  and  external  orilice  of  the 
uretha.  It  is  a  pyramid  of  elastic  tissue  and  of  striped  and  unstriped 
muscular  fibre.  It  forms  a  bracing  point,  therefore,  for  much  of  the 
musculature  of  the  pelvic  floor ;  namely,  for  sphincter  ani,  transversus 
perinei,  bulbo-cavernosus,  and  levator  ani  (Figs.  3,  7,  8,  and  9). 


LEVATOR  ANI 


Fio.  6.  —  Sphincter  ani  in  full-tiino  foetus. 

The  connective  tissue  of  the  female  pelvis  is  very  abundant  and  of  great 
importance.  It  packs  all  the  interstices  between  the  main  organs,  and  is 
of  great  pathological  interest,  as  in  it  run  the  lymphatics,  blood-vessels, 
and  nerves.  Although  the  pelvic  connective  tissue  is  practically  continu- 
ous, and  passes  up  into  the  iliac  fossae  and  abdominal  cavity,  it  is  con- 
venient to  recognise  it  as  being  present  in  the  following  situations:  — 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS 


39 


(a)  Round  the  cervix  uteri :  this  is  the  parametric  tissue  proper  of 
Virchow.  (&)  Between  the  broad  ligaments,  (c)  Between  the  poste- 
rior bladder  wall  and  cervix  uteri.  (cZ)  Between  the  vagina  and  the 
anterior  rectal  wall,  (e)  Between  the  bladder  and  the  pubes.  (f)  In 
the  ischio-rectal  fossa  and  below  the  peritoneum. 

By  some  anatomists  the  term  parametric  tissue  is  made  equivalent 
to  pelvic  connective  tissue. 


FEMORAL  VEIN 


BLADDER 
OBTURATOR  INTERNLtS 


VAQINA 
LEVATOR  ANl 


ISCHIO  RECTAL  FOSSA 


GLUTEUS  MAXIM 


PERINEAL  BODY 


Fig.  ' 


Axial  transverse  section  of  right  Imlf  of  female  pelvie  floor.     (Seen  from  behind.) 


We  have  also  in  the  pelvic  floor  an  arrangement  of  sheet  fascia  — 
the  pelvic  fascia  of  the  anatomist;  the  main  parts  of  wliich  can  be 
seen  in  the  diagrams  of  frozen  sections  (Figs.  7,  8,  and  9). 

The  blood-vessels  of  the  pelvis  consist  of  arteries  and  veins. 

The  arterial  supply  of  the  pelvis  is  derived  from  the  ovan'au  and 
uterine  arteries. 

The  ovarian  artenj  is  a  branch  of  the  aorta,  and  passes  along  the  ujv 
per  border  of  the  broad  ligament  below  the  level  of  the  Fallopian  tube. 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS 


41 


It  gives  branches  to  the  tube,  ovary,  and  round  ligament ;  and  then  at 
the  junction  of  tube  and  uterus  passes  tortuously  down  the  sides  of  the 
uterus  to  join  the  uterine  artery.    From  the  arch  thus  formed  at  the  side 
of  the  uterus  branches  pass  at  right  angles  into  the  uterine  substance. 
The  uterine  artery  is  a  branch  of  the  anterior  division  of  the  inter- 


SMAtL  INTESTINE 


CROAD  LIGAMENT 


ISCHIORECTAL  FOSSA 


FiQ.  9. — Axial  coronal  section  of  rig-lit  half  of  female  pehns.     (Seen  from  behind  :  dotted  line  =  fascia.) 


nal  iliac.  It  passes  downwards  and  inwards  towards  the  cervix  uteri, 
giving  a  well-marked  branch  to  the  cervix  —  the  circular  artery;  but 
sometimes  several  smaller  branches  take  its  place.  The  relation  of  the 
uterine  artery  to  the  ureter  must  be  kept  in  mind.  The  uterine  artery 
also  gives  branches  to  the  vagina ;  and  these,  with  branches  from  the 
circular  artery,  form  the  azygos  artery  of  the  vagina.  The  pndic  artei^i, 
a  branch  of  the  same  anterior  division  of  the  internal  iliac,  is  a  well- 
marked  vessel  at  the  outer  boundary  of   the  iscliio-rectal   fossa;  and 


SYSTEM  OF  GYNAECOLOGY 


from  it  we  get  the  superficial  and  transverse  perineal  arteries,  the 
artery  to  the  bulb,  corpus  spongiosum,  and  clitoris,  and  the  inferior 
htemorrhoidal  artery  (Figs.  10  and  21). 


OVABIAN  ARTERY 


UTERINE  ABTEHV 


Blood  si/pp/t/  o/ i/teri/s 


Fig.  10. 


The  venous  supply  of  the  pelvis  consists  of  many  anastomosing  plex- 
uses.    There  are  thus  vesical,  hoemorrhoidal,  labial,  vaginal,  iiterine. 


TO  LUMBAR  QLANDS 


ROUND  LIGAMENT 


TO  HYPOOASTHIO  QLANDS 


Fi«.  11.  —  Lyirii)tiatl<;s  of  uUm'iih.     (Poirier.) 


ovarian,  and  pampiniform  plexuses.    The  vesical,  vaginal,  h.'jcmorrhoidal, 
and  pudic  veins  open  into  the  internal  iliac,  and  this  passes  to  the  infe- 


THE   ANATOMY   OF   THE   FEMALE   PELVIC   ORGANS 


43 


rior  vena  cava.  An  important  point  is  that  the  superior  haeniorrhoidal 
vein  passes  to  the  portal  system,  and  we  thus  get  an  anatomical  explana- 
tion of  the  nienorrhagia  of  drunken  women.  The  pelvic  veins  are  un- 
provided with  valves.  The  uterine  plexus  opens  into  the  ovarian  veins  ; 
the  right  ovarian  vein  passing  to  the  inferior  vena  cava,  where  it  is 
provided  with  a  valve ;  the  left  to  the  renal  vein. 

The  lympliatics  (Figs.  11  and  12)  of  the  pelvis  begin  in  connective 
tissue  spaces,  form  plexuses,  and  are  so  arranged  that  those  from  definite 
areas  pour  into  dctiuite  groups  of  glands.     Thus  the  Ijanphatics  of  the 


6UP.  LUM.  GLAN03 


INF.  LUM-  GLANCS 


LYMPHATICS  OF 
CORPUS    UTERI 
LYMPHATICS  OF  OVARY 

ILIAC   LYMPH.  GLAND 
CEBVIOAL  LyMPH-QLAND 


FiQ.  12.  —  Lymphatics  of  uterus  .ind  pelvis.     (Poirier.) 

external  genitals  and  lower  fourth  of  the  vagina  pour  into  the  oblique 
inguinal  glands  ;  those  of  the  upper  three-fourths  of  the  vagina  and  cervix 
uteri  into  the  iliac  glands.  The  13'mphatics  of  the  body  of  the  uterus 
pass  along  the  broad  ligaments,  and,  accompanied  by  those  from  the  ovary 
and  Fallopian  tube,  reach  the  lumbar  glands.  The  lymphatics  of  the 
round  ligaments  open  into  the  inguinal  glands,  and  a  gland  lying  on  the 
obturator  membrane  also  establishes  a  communication  between  the  pelvic 
connective  tissue  and  the  inguinal  glands.  The  rectal  lymphatics  open 
into  the  sacral  glands ;  those  of  the  bladder  pass  to  the  iliac  glands. 


44 


SYSTEM   OF  GY.W-ECOLOGY 


These  facts  are  of  great  patliological  importance.  In  malignant 
disease  of  the  vulva  and  lower  fourth  of  the  vagina,  the  oblique  inguinal 
glands  are  affected;  but  in  cancer  higher  up,  the  pelvic  and  lumbar 
glands  are  first  infiltrated.  Through  the  lyinphatics  of  the  round  liga- 
ment, and  especially  through  the  obturator  gland,  we  may  have,  though 
rarely,  late  infection  of  the  inguinal  glands  in  uterine  cancer.  I  have 
now  several  times  seen  the  inguinal  glands  enlarged  in  pelvic  sarcoma, 
and  in  one  instance  I  found  the  obturator  gland  distinctly  enlarged. 

The  abundant  lymphatic  supply  of  the  pelvis  explains  the  inflamma- 
tory attacks  arising  from  sepsis  and  gonorrhoea,  and  abundant  evidence 
of  their  importance  will  come  up  afterwards.  Here  Ave  can  only  em- 
phasise the  great  importance  of  antiseptics  in  operative  work,  and  the 


Fig.  1-3.  —  Nerve  diaKram.     (Flower.) 

avoidance  of  all  minor  manipulations  with  the  sound  as  a  means  of 
diagnosis  in  the  consulting-room. 

The  nerves  of  the  pelvis  are  spinal  and  sympathetic.  The  levator 
and  sphincter  are  innervated  by  the  inferior  hseraorrhoidal  branch  of 
the  pudic,  and  by  the  fourth  and  fifth  sacral  and  coccygeal  nerves ;  the 
coccygeal  nerves  and  fourth  and  fifth  sacral  also  supply  the  coccygeus. 
Branches  of  the  pudic  nerve  pass  to  the  muscles  of  the  perineum  and 
clitoris. 

The  sympathetic  is  arranged  in  many  i)lexuses.  The  hypogastric 
plexus  between  the  common  iliac  arteries  gives  branches  which,  with 
those  from  lumbar  and  sacral  ganglia  and  sacral  nerves,  make  up  the 
inferior  hypogastric  plexuses  lying  on  each  side  of  the  vagina.  Branches 
from  them  ]jass  to  the  vagina,  uterus,  Fallo])ian  tubes,  and  ovaries. 

Special  end  bulbs  ai-e  found  in  the  clitoi'is  and  labia  minora.  In  the 
vagina  the  nerves  end  in  the  e])ithelium.  In  the  utei'us,  nerve  ])lexuses 
and  nerve  cells  are  yjreseiit  in  the  inuscular  coat,  and  the  nerve-endings 
can  be  traced  io  the  glands  and  epithelium. 


THE  ANATOMY  OF   THE  FEMALE  PELVIC   ORGANS 


45 


In  the  tube  the  nerves  are  arranged  in  two  concentric  plexuses, 
ending  in  the  epithelium  and  in  the  nerve  cells  of  the  subniucosa.  In 
the  ovary  the  nerve-endings  have  been  traced  to  the  Graafian  follicles 
and  cells  of  the  membrana  granulosa. 

Fain  is  so  common  a  gynaecological  symptom  that  it  is  remarkable 
that  gynaecologists  have  not  brought  more  precision  into  their  descrip- 
tions of  it.  In  a  recent  paper  in  Brain,  Dr.  Head  has  attempted  to  give 
greater  accuracy  to  the  definition  of  these  sympathetic  painful  areas  ; 
he  states  that  the  area  for  ovarian  pain  is  "  limited  above  by  a  line  run- 
ning horizontally  from  the  top  of  the  first  lumbar  spine  to  the  umbilicus ; 
below  by  a  line  running  from  the  third  lumbar  spine  to  midway  between 
the  pubes  and  umbilicus,  but  having  a  little  downward  tag  near  the  an- 
terior superior  iliac  spine."  For  the  body  of  the  uterus  and  Fallopian 
tubes  the  area  is  bounded  above  by  the  preceding  one ;  and  below  by  a 
line  running  from  a  little  below  the  top  of  the  sacrum  to  the  symphj-sis, 
but  having  a  dip  down  over  the  buttock,  and  another  over  the  front  of 
the  thigh.  For  the  cervix  uteri  the  painful  area  is  over  the  lower  part 
of  the  sacrum.  For  the  ovary,  therefore,  it  is  formed  by  the  sensory  fibres 
from  the  tenth  dorsal  nerve 
root ;  for  the  body  of  the 
uterus  and  Fallopian  tubes 
by  the  sensory  fibres  of  the 
eleventh  and  twelfth  dor- 
sal nerve  roots ;  and  for 
the  cervix  by  the  sensory 
fibres  of  the  third  and 
fourth  sacral  roots. 

IV.  The  anatomy  of 
the  organs  on  the  upper 
aspect  of  the  pelvic  floor 
—  that  is,  of  the  Uterus,  Fallopian  Tubes,  Broad  Ligaments,  and 
Ovaries ;  the  Pelvic  Peritoneum.  (Figs.  14  and  lo.)  Tim  Uterus.  — 
If  the  uterus  be  separated  from  its  appendages,  it  will  appear  as  a 
pear-shaped  body  with  a  constriction  —  the  isthmus  —  slightly  below 
its  middle,  dividing  it  into  two  great  parts,  the  body  and  cervix.  At 
its  inferior  extremity  is  the  os  uteri  externum ;  at  the  upper  right  and 
left  angles  lie  the  openings  of  the  Fallopian  tubes.  Its  anterior  surface 
is  more  flat  than  the  posterior,  and  only  the  upper  half  of  the  former 
is  covered  by  the  peritoneum.  If  a  vertical  mesial  section  be  made, 
we  can  then  see  that  the  uterus  has  a  cavity  or  slit,  that  its  walls 
are  about  half  an  inch  thick,  and  that  the  cavity  is  lined  by  mucous 
membrane  -^  inch  (1  mm.)  thick.  In  a  section  through  the  cavity, 
dividing  the  uterus  into  anterior  and  posterior  portions,  Ave  can  see 
the  shape  and  relations  of  its  cavity  more  clearly  displayed.  The  cer- 
vical canal  is  somewhat  spindle-shaped,  and  the  so-called  uterine 
cavity  consists  of  anterior  and  posterior  triangular  surfaces  which  nor- 
mally, and  in  the  unimpregnated  condition,  are  in  apposition.     The  os 


Fic  14. 


-Relations  of  uterus  and  ovaries  viewed  through 
brim.     (His.) 


46 


SYSTEM  OF  GYNECOLOGY 


uteri  externvim  is  the  lower  boundary  of  the  cervical  canal ;  the  upper 
boundary  is  less  definite,  but  for  practical  purposes  we  may  place  it  op- 
posite the  isthmus.  The  os  uteri  internum  is  the  lower  opening  of  the 
uterine  cavity  proper,  Avhile  to  the  right  and  left  above  are  the  internal 


Fio.  15.  — Sagittal  lateral  section  of  female  jjelvis.     L  points  to  iscliio-rectal  fossa. 

Openings  of  the  Fallopian  tubes.  These  three  i:)oints ;  namely,  the  os  uteri 
internum  and  the  Fallopian  tube  openings  —  map  out  the  normal  surface 
from  which  menstruation  takes  place,  and  where  normal  pregnancy  occurs. 
It  is  difficult  to  divide  the  unimprognated  uterus  accurately  into  its 
various  parts.  If  we  take  the  anterior  wall  of  the  uterus  we  may  con- 
sider it  as  made  up  of  three  portions  :  firstly,  the  cervix,  where  the  blad- 
der is  attached,  and  with  the  os  uteri  internum  as  its  upper  boundary  — 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS 


47 


the  average  measurement  of  this  is  an  inch :  secondly,  the  lower  uterine 

segment,  which  is  rudimentary,  and  is  bounded  below  by  the  os  uterine 
oLANo         QuvMo  internum,  and  above  by  the 

firm  attachment  of  the  peri- 
toneum—  it  measures  about 
half  an  inch,  and  has  not 
yet  been  accurately  mapped 
out :  thirdly,  the  body  of  the 
uterus  proper,  Avhich  begins 
where  the  peritoneum  is 
firml}'-  attached,  and  extends 
up  to  the  fundus. 

The  cervix  has  been 
divided  by  some  into  a  vag- 
inal, middle,  and  supravagi- 
nal portion ;  and  this  division 
is  of  importance  in  relation 
to  cervical  hypertrophies. 
The  vaginal  portion  is  the 
symmetrical,  unattached  part 
of  the  cervix  (Fig.  17) ;  the 
middle  portion  is  attached  to 
the  bladder  in  front,  but  is 
free  behind ;  and  the  suprar 
vaginal  portion  is  attached  to 
the  bladder  in  front  and  to 
the  vagina  behind. 

Structure  of  the  Uterus.  — 
The  outer  aspect  of  the  uterus 
is  covered  by  peritoneum,  ex- 
cept where  the  bladder  is 
attached.  Its  wall  is  half  an 
inch  thick,  and  made  up  of 

unstriped  muscular  fibre  and  connective  tissue.     The  mucous  membrane 

of  the  uterus  is  Jj-  of  an  inch  thick 

and  merits   special   description.      In 

the  cervical  canal  the  mucous   mem- 


FiG.  IG.  —  TJterine  tnncoiis  membrane  sho^vin 
glands  and  stroma. 


brane  has  a  peculiar  arrangement  visi- 
ble to  the  naked  eye — the  Avell-known 
arbor  vitae.  This  consists  of  a  vertical 
ridge  Avith  lateral  ones  slanting  up- 
wards and  outwards.  The  cervical  mu- 
cous membrane  consists  of  columnar 
epithelium,  ciliated  and  narrow,  with 
the  nucleus  deep  in  the  cell.  Many 
glands  of  a  racemose  type  are  present, 
and  penetrate  deeply  into  the  connective  tissue. 


Fio.  17. 


Cervix  and  upper  part  of  vapin.-i 
showing  nigra-. 

In  the  substance  of 


48  SYSTEM  OF  GYNMCOLOGY 

the  cervix  are  dense  connective  tissue  and  nnstriped  muscular  fibre.  The 
vaginal  portion  of  the  cervix  is  covered  with  many  la^^  ers  of  squamous 
epithelium"  continuous  with  and  similar  to  that  of  the  vagina.  The  mucous 
membrane  of  the  uterine  cavity  proper  is  ^V  of  an  inch  thick,  and  of  a 
grayish  red  colour  :  it  consists  of  a  surface  covering  of  columnar  epithe- 
lium and  an  embrj^onic  connective  tissue.  Numerous  so-called  "  glands  " 
open  on  its  surface,  and  ramify  and  intersect  in  all  directions  down  to  the 
muscular  coat.  There  is  no  submucous  connective  tissue.  The  "  glands  " 
are  lined  with  columnar  epithelium  of  the  same  nature  as  the  surface 
epithelium,  and  continuous  with  it.  So  far  as  my  observation  goes,  the 
epithelium,  does  not  rest  on  a  membrana  propria.  There  has  been  much 
discussion  as  to  the  nature  of  these  so-called  glands :  it  is  best  on  the 
whole  to  regard  them  not  as  specially  glandular,  biit  as  mere  pits  of  epi- 
thelium, honey-combing  the  mucous  membrane.  The  mucous  membrane 
is  really  a  lymphatic  tissue,  reticulated  with  epithelial  cliverticida  whose 
function  in  some  points  we  understand.  During  menstruation  there  is 
a  superficial  denudation  of  the  mucous  membrane ;  and  it  is  from  the 
epithelial  pits  and  the  connective  tissue  between  them  that  regeneration 
takes  place.  During  pregnancy  also,  we  have,  persisting  close  to  the 
muscular  coat,  the  funduses  of  these  pits  in  the  form  of  the  well-known 
spongy  layer.  This  arrangement  permits  not  only  of  the  separation  of 
the  placenta  and  membranes  during  the  third  stage  of  labour,  but  also 
gives  again  epithelium  and  connective  tissue  for  the  development  of  a 
new  mucous  membrane  during  the  puerperium.  The  connective  tissue 
itself  consists  of  elongated  cells  with  nuclei,  and  branching  small 
round  cells  anastomosing  with  one  another.  Leucocytes  when  present 
are  to  be  considered  pathological ;  and  the  same  is  the  case  in  regard 
to  unstriped  muscle  in  the  stroma.  According  to  Leopold,  the  bundles 
of  connective  tissue  are  surrounded  by  endothelial  cells,  which  thus 
form  lymph  spaces. 

The  Fallopian  tubes  are  two  in  number,  and  pass  out  from  the  right 
and  left  upper  angles  of  the  uterus  towards  the  side  of  the  pelvis  in  a 
way  to  be  described  more  fully  afterwards.  Each  is  about  10  cm.  in 
length,  and  lies  below  the  upper  margin  of  the  broad  ligament.  They  are 
covered  by  the  x^eritoneum  for  about  five-sixths  of  their  periphery,  the 
remaining  and  lower  sixth  resting  on  the  connective  tissue  between  the 
layers  of  the  broad  ligaments.  The  following  divisions  are  recognised : 
a  portion  piercing  the  wall  of  the  uterus,  the  interstitial  part;  a  straight 
portion,  or  isthmus  ;  a  curved  portion,  the  ampulla;  and,  finally,  the  fim- 
briated end,  with  the  special  ovarian  fimbria.  The  tube  consists  of  a 
jteritoneal  covering;  a  muscular  coat  in  two  layers,  circular  inner  and 
longitudinal  outer ;  and  a  remarkaljly  folded  mucous  membrane.  The 
mucous  membrano  lining  the  tube  is  continuous  with  that  of  the  litems, 
and  is  thrown  into  many  longitudinal  folds  wliicli  ])ass  out  into  the  fim- 
briated end.  In  the  fimbriated  end  can  be  seen  the  ostium  abdoniinale  or 
outer  opening  of  the  tube.  One  special  fimbria,  the  ovarian  fimbria,  joins 
the  ovary  and  tube.     We  must  note  here  the  remarkable  fact  that  the 


THE   ANATOMY   OF  THE   FEMALE   PELVIC   ORGANS 


49 


genital  tract  of  woman  communicates  by  this  ostium  directly  with  the 
peritoneal  cavity  (Figs.  14  and  15). 

The  mucous  membrane  of  the  Fallopian  tube  consists  of  columnar 
epithelium  and  connective  tissue.  The  foldings  of  the  mucous  membrane 
are  very  much  less  marked  in  the  isthmus,  much  more  so  in  the  ampulla. 
The  question  whether  these  foldings  constitute  glands  is  still  disputed ; 
but  I  see  no  valid  reason  as  yet  for  considering  them  as  an3-thing  more 
than  a  honey-comb  arrangement  of  the  tubal  lining,  indicating,  so  far 
as  we  know  at  present,  its  close  developmental  relation  to  the  uterus. 
The  calibre  of  the  isthmus  is  such  as  to  admit  a  bristle,  while  the  ampulla 
will  admit  the  ordinary  uterine  sound. 

The  tube  in  the  foetus  has  windings  in  it  of  a  pathological  interest. 
The  hiidatid  of  Morgagni,  derived  from  the  duct  of  Muller,  is  attached  to 
the  fimbriie  or  tube,  and  has  a  mucous  columnar  lining  A\ith  clear  fluid. 
Muscle  and  peritoneum  make  up  its  head  and  stalk.  It  must  not  be 
confounded  with  cysts  in  the  mesosalpinx  arising  from  "Wolffian  relics. 

Ovaries.  —  The  ovaries,  two  in  number,  lie  projecting  from  the  poste- 
rior lamina  of  the  broad  ligament,  and  on  the  side  walls  of  the  pelvis.  The 
diameter  of  each  ovary  is  1^  inch  by  f  by  |  of  an  inch.  The  posterior 
surface  looks  backwards,  the  anterior  is  attached  to  the  broad  ligament; 
their  long  axis  is  either  perpendicular  or  somewhat  transverse.  The 
part  of  the  ovary  joining  the  broad  ligament  is  named  the  hilum. 

Structure  of  the  Ovary.  —  The  ovary  is  covered  on  its  outer  aspect  by 
columnar  epithelium,  the  germ 
epithelium  of  Waldeyer,  who 
first  indicated  its  nature  and 
importance  in  development.  At 
the  hilum  the  germ  epithelium 
is  continuous  with  the  squa- 
mous epithelium  of  the  broad 
ligament,  the  bomidary  being 
marked  by  the  Avell-known 
white  line  of  Farre.  In  fresh 
specimens  the  ovary  has  a  dull, 
pearly  lustre,  the  broad  liga- 
ments being  more  grayish. 
AVhile  Farre  drew  attention  to  this  line  of  demarcation,  he  unfortunately 
omitted  to  note  the  real  nature  of  the  covering  of  the  ovary,  a  mistake 
readily  made  if  he  examined  adult  ovaries  only. 

Below  the  germ  epithelium  lies  the  tunica  albuginea.  a  condensed 
concentric  arrangement  of  connective  tissue.  On  section  we  see  that 
the  rest  of  the  ovary  is  made  up  of  two  portions,  a  cortical  or  outer  zone, 
and  a  medullary  or  vascular  zone  continuous  Avith  the  tissue  of  the  broad 
ligament.  In  the  cortical  portion,  and  surrounded  by  connective  tissue, 
we  have  the  remarkable  structures  known  as  the  Graafian  follicles.  Each 
ovary  contains  a  very  large  number  of  these  follicles,  but  whether  they 
amount  to  eighty  or  ninety  thousand,  as  some  authors  allege,  is  not  quite 


Fic.  18. — Seal's  ovary  sliowiiifr  cortical   and   nu'dullai-y 
layers,  also  peritoneal  capsule  with  tube  on  section. 


50 


SYSTEM  OF  GYNECOLOGY 


certain.  The  Graafian  follicles  near  the  surface  of  the  ovary  are  small, 
the  larger  ones  being  deeper ;  but  a  few  of  the  largest  lie  at  the  periphery. 
Each  Graafian  follicle  consists  of  a  tunica  fibrosa  and  a  tunica  propria, 
the  so-called  membrana  granulosa,  lined  with  columnar  cells  and  con- 
taining the  liquor  folliculi.  Usually  the  membrana  granulosa  has  a 
projection  of  cells,  the  discus  proligerus,  which  contains  the  ovum 
proper.  The  ovum  is  made  np  of  zona  pellucida,  yelk,  germinal  vesicle, 
and  germinal  spot  (nucleus  and  nucleolus).  The  columnar  cells  im- 
mediately surroimding  the  ovum  form  the  corona  radiata.     The  fresh 


CERM    EPJTHELIUM 


Fig.  19.  —  Sagittal  lateral  section  of  genital  organs  in  85  months'  foetus.  Note  proximity  of  rectal  and 
broad  ligament  connective  tissue ;  the  relations  of  ureter,  ovary,  and  uterine  artery  are  the  same 
in  the  adult. 


nucleolus  has  been  noted  to  have  amoeboid  movements.  The  ovary  lies 
in  a  shallow  depression  of  peritoneum,  the  fossa  ovarii.  In  some  of  the 
lower  animals,  such  as  the  rat  and  seal,  the  ovary  is  surrounded  by 
peritoneal  capsule,  and  thus  is  shut  off  from  the  general  peritoneal  cavity. 
It  is  alleged  that  the  same  arrangement  may  occur  in  the  human  female, 
and  be  a  source  of  tubo-ovarian  cysts  (lUand  Sutton).  The  connective 
tissue  consists  of  round  cells,  and  at  the  hilum  are  many  blood-vessels. 

Pelvic  Peritoneum.  —  The  upper  aspect  of  the  pelvic  floor,  the  uterus, 
and  its  appendages  are  covered  by  peritoneum,  the  arrangement  of  which 
must  now  be  described. 

On  sagittal  mesial  section  the  arrangement  is  as  follows,  from  before 
Vjackwards :  — The  peritoneum  of  the  anterior  abdominal  wall  is  reflected 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS  51 

on  the  fundus  of  the  bladder  a  little  above  the  level  of  the  pubes.  It 
then  passes  on  to  the  anterior  surface  of  the  uterus,  about  tlie  level  of  the 
OS  internum,  over  the  fundus,  and  down  the  posterior  wall  of  the  uterus, 
which  it  covers  completely.  It  dips  down  on  the  uppermost  half  inch  of 
the  posterior  vaginal  wall,  and  finally  becomes  reflected  upon  the  sacrum 
and  rectum.  The  vesico-uterine  pouch  of  peritoneum  lies  between  the 
bladder  and  uterine  Avail.  The  posterior  dip  of  the  peritoneum  below  the 
level  of  the  isthmus  is  known  as  the  pouch  of  Douglas ;  it  will  be  more 
fully  described  shortly.  The  vesico-uterine  pouch  has  sometimes  been 
erroneously  termed  the  space  of  lietzius  (Figs.  3  and  7). 

The  broad  ligaments  are  formed  by  two  folds  of  peritoneum  passing 
out  from  the  sides  of  the  uterus  to  the  side  wall  of  the  pelvis.  The 
anterior  fold  of  the  broad  ligament  is  a  continuation  of  the  peritoneum  on 
the  anterior  surface  of  the  uterus.  Beneath  it  lies  the  well-known  round 
ligament,  which  passes  from  the  junction  of  the  Fallopian  tube  and 
uterus,  forwards  and  outwards  to  the  inguinal  canal.  These  round 
ligaments  contain  striped  and  unstriped  muscular  fibre,  blood-vessels,  and 
nerves.  The  posterior  lamina  of  the  broad  ligament  is  in  the  same  way 
a  prolongation  outwards  and  backwards  of  the  peritoneum  on  the  posterior 
surface  of  the  uterus.  It  is  larger  than  the  anterior  lamina,  and  lies 
partly  on  the  side  wall  of  the  pelvis.  Thus  the  ovary  comes  to  lie  both 
on  the  posterior  aspect  of  the  broad  ligament  and  on  the  side  wall  of 
the  pelvis.  Between  the  layers  of  the  broad  ligament  lie  connective 
tissue,  blood-vessels,  lymphatics  and  nerves ;  the  connective  tissue  passing 
up  into  that  of  the  iliac  fossa.  The  so-called  ovarian  ligament  joins  the 
lower  end  of  the  ovary  and  the  angle  between  tube  and  uterus;  the 
uterine  muscle  passes  into  it.  The  Fallopian  tube  occupies  the  greater 
part  of  the  top  of  the  broad  ligament.  The  infundibulo-pelvic  ligament 
of  the  ovary  is  that  part  of  the  top  of  the  broad  ligament  not  occupied  by 
Fallopian  tube,  and  to  a  certain  extent  it  suspends  the  ovary.  The  paro- 
varium also  lies  between  the  layers  of  the  broad  ligament  near  the  ampulla, 
and  consists  of  a  single  longitudinal  tube  with  several  vertical  ones.  It 
represents  the  i-emains  of  the  Wolffian  duct  and  body,  and  will  be  more 
particularly  alluded  to  afterwards.  The  utero-sacral  folds  are  two  ridges 
of  peritoneum  enclosing  muscular  fibre  and  connective  tissue;  they  pass 
one  from  each  side  of  the  isthmus  uteri,  outwards  and  backwards  towards 
the  second  and  third  sacral  vertebrae.  The  pouch  of  Douglas  can  now  be 
more  accurately  defined.  Its  upper  lateral  limits  are  the  utero-sacral 
folds ;  in  front  the  isthmus  forms  the  anterior  boundary,  behind  is  the 
peritoneum  covering  the  sacrum  and  rectum.  The  fact  that  so  many 
pathological  products  are  found  in  the  pouch  of  Douglas,  or  its  neigh- 
bourhood, is  to  be  explained  not  only  by  its  affording  an  actual  pouch 
for  lodgment,  but  by  the  near  presence  of  the  ovary;  and  above  all  by 
the  fact  that  the  openings  of  the  Fallopian  tubes  lie  posterior  to  the 
broad  ligament.  Between  the  utero-sacral  fold  and  the  broad  ligament 
lie  the  lateral  pouches  of  Douglas,  while  on  each  side  of  the  bladder 
there  is  a  para-vesical  pouch. 


SYS7^£M   OF  GYN.F.COLOGY 


V.     The    Position    of    the    Organs :     their    dissection  and   structural 

anatomy.  —  The  position  of  the  organs  is  best  ascertained  and  described 
in  an  adult  pelvis  which  has  been  hardened  and  the  superjacent  intestine 


carefully  removed.  One  of  the  best  of  these  drawings  has  been  recently 
published  by  Waldeyer  (Fig.  20).  The  vterus  lies  below  the  level  of  the 
brim,  iisually  to  the  one  side,  and  is  anteverted  and  anteflexed.    Viewed 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS  53 

from  above,  therefore,  one  can  only  see  its  fundus  and  posterior  surface. 
The  anterior  surface  touches  the  bladder,  so  that  the  vesico-uterine  pouch 
is  usually  empty.  The  normal  uterus  is  perfectly  mobile,  and  its  shape 
and  normal  relation  to  the  vagina  is  a  developmental  one.  Those  who 
advocate  ventro-fixations  seem  to  forget  entirely  that  the  uterus  is  a 
mobile  pelvic  organ,  and  that  after  such  operations  it  lies  for  a  time  in 
a  state  of  abnormal  position  and  fixation. 

The  Fallopian  tubes  pass,  firstly,  out  towards  the  side  of  the  pelvis; 
they  then  turn  up,  and  the  fimbriated  end  becomes  applied  to  the  pos- 
terior aspect  of  the  ovary. 

The  ovary  lies  on  the  posterior  lamina  of  the  broad  ligament,  on  the 
side  wall  of  the  pelvis,  below  the  level  of  the  brim,  and  in  front  of  the 
sacro-iliac  joint.  The  ovary  on  the  side  of  the  pelvis  to  which  the  uterus 
is  inclined  has  its  long  axis  vertical  (Fig.  14) ;  the  other  ovary  has  its 
long  axis  more  or  less  transverse. 

The  vagina  runs  through  the  pelvic  floor  parallel  to  the  conjugate. 
The  part  of  the  rectum  in  relation  to  the  vagina  and  to  the  urethra  is 
also  parallel  to  the  conjugate.  The  long  axis  of  the  anus  is  parallel  to 
the  axis  of  the  pelvic  brim.  The  external  genitals  in  the  upright 
posture  make  a  small  angle  with  the  horizon. 

Dissection  of  the  Pelvis. — If  a  cadaver  be  placed  in  the  lithotomv 
posture  a  dissection  may  be  made  over  the  rectal  portion  of  the  peri- 
neum, and  also  of  the  anterior  urethral  portion.  When  in  the  former 
case  the  skin  is  suitably  removed,  we  come  upoii  the  superficial  fascia 
with  much  fat,  and  the  base  of  the  ischio-rectal  fossae.  If  the  fat,  super- 
ficial vessels,  and  nerves  be  removed  from  these  we  then  see  that  each 
fossa  is  bounded  on  the  inside  by  the  levator  ani,  and  on  the  outside  by 
part  of  the  obturator  internus.  The  varying  portion  of  these  boundaries 
is  best  seen  on  section  (Figs.  7,  8,  9).  Between  them,  the  sphincter  ex- 
ternus  can  be  dissected  out.  The  pudic  artery  lies  on  the  inner  aspect 
of  the  ischial  tuberosity.  If  the  skin  be  now  removed  from  the  anterior 
urethral  portion  Ave  come  first  upon  the  superficial  fascia,  and  then  on 
the  deep  layer  of  the  superficial  fascia.  This  latter  is  attached  to  the 
pubic  arch,  its  base  hooking  roimd  the  trans versi  perinei  to  join  the  an- 
terior layer  of  the  triangular  ligament.  On  its  removal  we  now  see  a 
double  triangular  arrangement  of  muscles,  one  on  each  side  of  the  middle 
line.  The  base  of  each  triangle  is  formed  b}'  the  transversus  perinei,  the 
outer  side  by  the  erector  clitoridis,  the  inner  by  the  bulbo-cavernosus  or 
sphincter  vaginoe.  Below  the  lower  end  of  the  bulbo-cavernosus  lies 
the  Bartholinian  gland  with  its  duct  opening  at  the  sides  of  the  hymen. 
Higher  than  the  Bartholinian  glands,  and  still  below  the  bulbo-caverno- 
sus, lie  the  erectile  structures  known  as  the  bulbi  vaginte.  The  removal 
of  these  muscles  now  exposes  the  anterior  layer  of  the  triangular  liga- 
ment. This  layer  having  been  dissected  olf,  we  come  upon  the  terminal 
branches  of  the  pudic  vessels  and  nerves  lying  on  tlie  posterior  layer, 
aiul  then  cut  into  the  retro-piibic  fat.  The  exact  relations  of  the  fascia 
here  have  not  yet,  however,  been  accurately  worked  out.     The  triangular 


54 


SyST£J/   OF  GYNAECOLOGY 


ligament  undoubtedly  acts  as  a  supporting  element  to  the  urethra  and  va- 
gina. Avhich  perforate  it ;  and  in  the  rare  cases  where  a  nullipara  suffers 
from  prolapsus  uteri  the  edge  of  the  triangular  ligament,  where  it  is 
perforated  by  the  vagina,  can  be  felt  like  a  ring  (Fig.  21). 


Fig.  21.  —  Pei-ineal  region. 


If  a  dissection  be  now  made  from  above,  and  the  peritoneum,  uterus, 
and  appendages  removed,  the  pelvic  diaphragmatic  mus(tles  will  be  ex- 
])0sed.  These  are  the  coccygei  and  the  levatores  ani ;  and  viewed  from 
above  they  form  a  concave  muscular  arrangement.  The  levator  ani  has  its 
origin  from  the  posterior  aspect  of  the  pubes,  from  the  white  line  of  fascia. 


THE   ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS 


55 


and  the  ischial  spine.    The  fibres  pass  down,  almost  vertically,  to  become 
attached  to  the  vagina,  the  rectum,  its  fellow,  and  the  tip  of  the  coccyx. 

The  coccygeus  has  its  origin  from  the  spine  of  the  ischium  and  passes 
to  the  lower  part  of  the  sacrum  and  front  and  side  of  coccyx. 

The  obturator  internus  is  well  seen  in  the  sections  (Figs.  7,  8,  9). 

Structural  Anatomy.  —  In  sagittal  mesial  section  the  pelvic  floor  is  an 
unbroken  layer.  The  vagina  and 
urethra  do  not  impair  its  strength, 
as  they  are  slits  passing  through 
it  at  right  angles  to  the  direction 
of  intra-abdominal  pressure.  The 
floor,  however,  can  be  divided 
into  two  portions,  —  an  anterior 
pubic  mobile  segment,  and  a 
posterior  more  fixed  or  sacral 
segment.  The  vagina  thus  forms 
a  boundary  between  these  two. 
The  pubic  segment  consists  of 
bladder,  urethra,  and  anterior 
vaginal  wall.  Its  mobility  is 
due  not  only  to  the  less  firm  nat- 
ure of  its  tissue,  but  also  to  its 
loose  attachment  to  the  pubes. 

The  sacral  segment  is  firmly 
attached  to  the  sacrum,  and  con- 
sists of  the  tissue  behind  the 
posterior  vaginal  wall,  which  is 
included  in  it.  In  the  upright 
posture  the  sacral  segment  is  the 
supporting  one,  intra-abdominal 
pressure  pressing  the  pubic  seg- 
ment against  it. 


Fig.  22. 


-  Sacral  section  of  pelvic  floor. 

Changes  in  pelvic  floor  due  to  jyosture.  —  In  the  position  known  as  the 
genu-pectoral  the  abdominal  bulge  lessens  at  the  pubes  and  increases 
near  the  diaphragm.  The  projection  of  the  pelvic  floor  is  also  less 
marked ;  but  the  pelvic  floor  is  still  unbroken.  The  following  facts  are 
now  of  great  importance:  —  If  the  edges  of  the  hymen  be  separated,  air 
passes  in  and  the  vaginal  slit  becomes  a  cavity.  The  uterus  if  ante- 
verted  previously  becomes  more  so,  and  lies  farther  from  the  vaginal 
orifice.  The  retroverted  unfixed  uterus  does  not  become  anteverted  when 
a  patient  assumes  the  genu-pectoral  posture,  and  air  is  admitted  into  the 
vagina;  but  the  uterus  lies  farther  from  the  vaginal  orifice  and  becomes 
more  retroverted.  These  facts  as  to  the  dilatation  of  the  vagina  by 
posture  give  the  key  to  proper  specular  examination,  as  was  first  shown 
by  IMarion  Sims.  The  same  dilatation  of  the  vagina  can  be  attained  in 
the  position  known  as  Sims'  semiprone  posture,  and  also  in  the  lithotomy 
posture,  especially  if  the  hips  be  raised.    These  postural  methods  are  also 


56 


SYSTEM  OF  GYNAECOLOGY 


invaluable  in  rectal  and  vesical  examination.  In  the  same  way  the 
rectum  can  be  ballooned,  and  also,  as  Kelly  has  shown,  the  bladder.^ 
In  this  Waj^,  and  by  simple  specula,  thorough  visual,  and,  in  certain 
cases,  digital  examination  of  the  bladder,  vagina,  and  rectum  can  be 
made ;  as  will  be  fully  explained  in  the  appropriate  section.  In  exam- 
ination of  bladder  cases  the  genu-pectoral  posture  is  advantageous,  as 
well  as  in  reposition  of  the  gravid  retroverted  uterus. 

VI.  Surgical  Anatomy.  — In  operative  pelvic  surgery  by  the  vaginal 
route  the  following  points  must  specially  be  kept  in  mind:  — 

i.  The  'posture  of  the  jMtient  mid  the  mobility  of  the  uterus.  —  There 
is  no  doubt  that  the  lithotomy  posture  is  the  most  convenient 
for  all  operative  work.  By  means  of  a  broad,  short,  modified  Sims' 
speculum  the  vagina  becomes  dilated  in  this  posture ;    and  then  with 


Fig.  23.  — Diagram  of  genu-pectoral  posture  showing  vaginal  distension.     (Based  on  frozen  seetioii.) 

the  volsella  the  uterus  can  in  most  instances  be  safely  drawn  near  the 
vaginal  orifice,  and  an  accessible  field  of  operation  thus  obtained.  By 
most  operators  the  use  of  the  semiprone  posture  has  been  abandoned 
for  the  more  convenient  lithotomy  one. 

ii.  Blood-supply :  Lines  of  loose  connective  tissue  in  the  pelvis  allowing 
the  separability  of  the  organs. — In  the  flap  operations  on  tlie  perineum, 
now  so  generally  adopted,  the  loss  of  blood  is  trifling.  The  bleeding 
is  mainly  venous,  and  is  readily  checked  by  j)ressure.  In  making 
the  usual  perineal  incision  with  scissors  it  is  advantageous  to  have  the 
thighs  well  flexed  on  the  abdomen,  so  as  to  render  the  parts  tense.  In 
suturing,  the  flexion  should  be  less  marked. 

The  lines  of  loose  tissue  in  the  pelvis  are  of  the  greatest  importance 
from  an  operative  point  of  view.  Thus  if  a  transverse  incision  be  made 
over  the  base  of  the  perineal  body,  so  as  to  split  it  into  anterior  and 
posterior  parts,  the  finger  can  then  pass  into  the  loose  tissue  between  the 
anterior  rectal  wall  and  posterior  vaginal  wall ;  and  these  can  be  easily 

1  Pawlik  of  Prague  claims  priority  iu  this. 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS  57 

separated  till  the  peritoneum  of  the  pouch  of  Douglas  is  reached.  In 
this  way  dermoids  of  the  recto-vaginal  septum  have  been  enucleated,  and 
also  certain  forms  of  deeply  burrowing  extraperitoneal  gestation  attacked. 
This  route  is  one  seldom  followed,  but  it  is  worthy  of  being  kept  in  mind. 
The  loose  union  between  rectum  and  vagina  allows  of  posterior  eol- 
porraphy  operations.  The  operator  can  make  a  vertical  mesial  incision 
on  the  posterior  vaginal  wall  imtil  the  loose  tissue  is  reached ;  he  can 
then  separate  laterally,  with  the  handle  of  his  knife,  the  posterior 
vaginal  wall,  remove  what  seems  necessary,  and  suture.  I  must  also 
point  out  that  this  loose  union  between  anterior  rectal  and  posterior 
vaginal  wall  is  an  important  factor  in  allowing  prolapse  of  the  uterus.  In 
the  same  way  the  loose  tissue  between  the  bladder  wall  and  the  upper 
portion  of  the  anterior  vaginal  wall  alloAvs  of  anterior  colporraphy. 

In  vaginal  hysterectomy  the  operator  readily  cuts  by  a  transverse 
incision  through  the  posterior  fornix  into  the  pouch  of  Douglas,  as 
the  thickness  of  tissue  here  is  only  \  inch.  Anteriorly  a  transverse 
incision  in  the  vaginal  fornix  exposes  the  loose  tissue  between  the 
bladder  and  cervix,  and  the  vesico-uterine  pouch  can  soon  be  opened. 
Here  as  a  rule  little  bleeding  arises,  but  it  is  qiiite  otherwise  with  the 
lateral  attachments  of  the  cervix;  there  the  tissue  is  dense  and 
abundantly  vascularised  by  the  uterine  artery.  Before  cutting  the 
lateral  attachments,  therefore,  it  is  imperative  for  the  operator  either 
to  ligature  or  to  apply  pressure  forceps:  the  anatomy  of  the  ureter 
must  also  be  kept  in  mind,  as  there  is  less  than  |  inch  between  it 
and  the  cervix  uteri.  When  once  the  firm  lateral  attachments  of  the 
cervix  have  been  thus  separated  the  uterus  can  be  more  thoroughly 
drawn  down,  and  the  broad  ligaments  secured  in  the  same  way  as  in  the 
case  of  the  lower  lateral  attachments. 

Operations  on  the  upper  part  of  the  vulva  are  usually  superficial,  as 
in  clipping  away  irritable  skin  in  pruritus  vulvae.  The  bleeding  is  usu- 
ally insignificant,  even  if  the  glans  clitoridis  be  cut  off.  The  operator 
must  beware  of  cutting  below  the  apex  or  sides  of  the  pudic  arch. 

In  abdominal  surgery  the  anatomy  of  the  incision  in  the  linea  alba 
needs  no  remark.  In  pelvic  adhesions  the  operator  must  be  specially  careful 
in  the  neighbourhood  of  the  sacro-iliac  joint  and  side  of  the  pelvis  owing  to 
the  position  of  the  ureter  here,  and  to  the  proximity  of  the  large  iliac  vessels. 

Recently  DVdirssen  and  Martin  have  recommended  in  certain  cases, 
instead  of  abdominal  section,  incision  by  way  of  the  loose  tissue  between 
the  bladder  and  the  uterus. 

VII.  Development  of  the  Organs.  —  The  subject  of  the  development 
of  the  female  genital  organs  is  too  complex  to  admit  of  full  consideration 
here,  and  I  shall  therefore  only  take  up  some  points  of  practical  impor- 
tance. In  a  human  fo?.tus  of  about  the  sixth  week  an  important  stage  is 
displayed.  This  can  be  Avell  seen  in  the  diagrams  obtained  in  a  fa?tus 
carefully  prepared  in  transverse  serial  section  by  my  former  assistant.  Dr. 
(rulland.  The  foetus  Avas  obtained  from  a  case  of  extirpation  of  a  six 
weeks'  pregnancy,  where  cancer  of  the  cervix  was  present;  it  was  thus 


58 


SVSTEA/   OF  GYNECOLOGY 


perfectly  fresh  and   in  all  respects  normal.     In  the  diagram  of  the 
transverse  section  of  the  abdominal  cavity  are  seen  the  two  Wolffian 


bodies,  markedly  developed  (Fig.  25).  Lower  down  (Fig.  2G)  they  have 
diminished  in  size,  and  are  represented  only  by  a  few  tubules ;  while  the 
ovary,  pedunculated  and  with  well-marked  germ  epithelium  covering  it. 


THE  ANATOMY   OF   THE   FEMALE  PELVIC   ORGANS 


59 


can  be  noted  (Figs.  26  and  28).     The  broad  ligaments  with  the  duct  of 
Miiller  can  also  be  seen. 

Lower  down  in  the  pelvis  the  genital  cord  is  displayed  (Fig.  27) ; 


WOLFRAM  BODY 


V/OUrFlAN  BODY 


Fig.  25.  —  T.  S.  ofWolffian  bodies  in  six  weeks'  foetus. 

and  at  this  stage  one  can  note  three  canals  in  it ;  the  centre  one  being 
formed  by  the  coalesced  ducts  of  Miiller,  while  each  lateral  one  is  the 
Wolffian  duct.    This  agrees,  therefore,  with  the  usual  statement  that  in 


WOLFFJAN   BODY 


•    / 


^  '/n:-< 


Fio.  2Ck  —  T.  S.  pelvis,  si.t  weeks'  fcetus.     Xote  wide  transverse  of  pelvis. 

the  early  foetus  there  are  two  sets  of  organs  —  the  Wolffian  bodies  with 
their  ducts,  and  the  ducts  of  Miiller.  The  former  atrophy  in  the  female 
sex  but  leave  their  traces  in  the  broad  ligaments,  where  are  normally  found 
the  parovarium,  or  epoophoron  (Fig.  28),  and  also  certain  additional  but 


6o 


SVSTJEM   OF  GYNECOLOGY 


occasional  relics  in  tlie  form  of  tubules  at  the  liilum,  or  of  a  special 
tube,  in  the  broad  ligament,  uterus,  or  vagina,  rarely  continuous  in  all 


SPiNAL  CORD 


VERTEBRA 


DUCTS  OF  MULLER 

AND  AT  SIDE 
WOLFFIAN    DUCTS 


;-*^v 


^^ 


if 


Fig.  27.  —  T.  S.  of  six  weeks'  fcetus  showing  genital  cord,     a  points  to  tissue  in  front  of  urino-genital 
sinus.     On  the  posterior  wall  of  the  sinus  is  the  eminence  where  the  ducts  of  iMiiller  end. 

of  them,  knoAvn  as  Gartner's  canal.     It  represents  the  Wolffian  duct, 

and  may  be  a  source  of  retention  cyst 
in  the  localities  already  named ;  it  is 
normally  present  in  the  cow  and  sow. 
The  ovary  develops  as  an  epithelial 
thickening  on  the  Wolffian  body.  The 
outer  cells  of  the  ovary  form  the  germ 
epithelium  of  Waldeyer,  which,  by 
sending  prolongations  into  the  sub- 
stance of  the  ovary,  forms  the  ova. 

The  ducts  of  Milller  give  rise  to 
the  Fallopian  tubes,  uterus,  and  vagina. 
They  remain  separate  to  form  the  tubes, 
and  coalesce  to  form  the  uterus  and 
vagina.  Disturbance  in  this  normal 
coalescence  gives  rise  to  malformations.  According  to  some  anato- 
mists, the  Wolffian  ducts  enter  into  the  formation  of  the  vagina,  and 
give  rise  to  the  H-shape  on  transverse  section.  As  the  diagram  shows, 
the  ducts  of  Midler  forming  tlio  vagina  at  first  have  a  lumen;  l)ut  by 
epithelial  proliferation  from  the  Wolffian  bulbs  they  become  solid.    At 


Xtrfj^ 


Fig.  28.  —Section  of  ovary  and  Wolffian  body, 
human  embryo,  third  month.  (Nagel.) 
md.  Duct  of  Mijiler,  par,  paroophoron; 
ejto,  epuophoron  (that  is,  parovarium). 


THE  ANATOMY   OF   THE   FEMALE   PELVIC   ORGANS 


6i 


the  lower  part  of  the  vagina  there  develop  about  the  third  and  a  half 
month  two  special  oval  epithelial  proliferations,  which  break  down  cen- 
trally and  thus  form  the  hymen  (Fig.  29).  These  bulljs  I  have  recently 
found  to  be  developed  from  the  Wolffian  ducts,  and  I  have  termed  them 


UTERINE  CAVITY 


VAOmA   (  NO  L 


Fig.  29.  —  L.  S.  of  85  months'  foetus  to  show  development  of  hymen.  Tliis  shows  formation  of  hymen 
by  development  of  two  bulbs  from  Wolthan  ducts  :  these  join  and  break  down  in  the  centre,  and 
are  met  by  an  involution  of  hypoblast  below. 

the  Wolffian  bulbs.  This  figure  also  shows  the  involution  of  the  deeper 
layers  of  the  vestibule  to  meet  the  hymen.  About  the  fourth  or  fifth 
month  the  solid  vaginal  proliferation  flattens  out,  and  then  forms  a 
lumen.     I  believe,  however,  that  it  may  do  so, earlier  (Figs.  27  and  29). 

In  the  early  foetus  (fifth  to  sixth  week)  a  cloaca  is  present;  the 
Wolffian  ducts  open  into  the  urino-genital  sinus  (Fig.  27)  up  till  the 
third  month,  Avhen  they  are  closed  by  the  development  of  the  hymen. 
The  subsequent  stages  are  the  formation  of  a  septum  and  the  develop- 
ment of  the  clitoris  in  front,  and  labia  at  the  sides. 

The  relation  of  the  pelvic  organs  to  the  germinal  layers  is  of  interest. 


62 


SYSTEM    OF  GYNAECOLOGY 


The  uterus,  tubes,  and  ovary  are  mesoblastic ;  tlie  adult  vagina  has  its 
lining  derived  from  the  epiblast,  the  lower  involution  from  the  local 
outer  covering,  but  the  lining  above  the  outer  aspect  of  the  hymen  is 
furnished,  as  an  examination  of  my  specimens  seems  to  me  to  demon- 
strate, tlirough  the  Wolffian  duct.  The  Wolffian  duct  is  really  epiblastic 
in  its  origin.  The  anus  is  also  epiblastic,  while  the  bladder  and  rectum 
are  hypoblastic.  The  vestibule  is  derived  from  the  urino-genital  sinus, 
and  is  hypoblastic. 

The  main  practical  points  resulting  from  this  development  are  as 
follows :  — 


Fig.  80. — Diagram  of  developing  and  fully  formed  genital  tract.  Ota,  Ostium  tubas  abdominale  ;  Km, 
hydatis  Morgagni ;  fo,  ovarian  fimbria  ;  o,  ovary  ;  lo,  ovarian  ligament ;  po,  parovarium  ;  Ir^  round 
ligament ;  rf/,  vagina  ;  vov,  upper  wall  of  vestibule  ;  cc,  corpus  cavcrnosum  clitoridis ;  u,  ureter ;  I, 
labium  minus;  Vm,,  labium  majus;  wh,  Wolffian  body.  On  the  right  side  are  seen  the  normal 
organs,  on  the  left  the  Woltlian-body  relics  and  duct  in  addition.     (Coblenz.) 

1.  Normally  in  the  adult  woman  we  find  traces  of  the  Wolffian 
body  and  duct  in  the  parovarium  (Fig.  30).  This  is  the  source  of  the 
ordinary  parovarian  tumour. 

2.  Skene's  tubules  in  the  urethra  are  probably  not  Wolffian  relics, 
h)ut  represent  the  glands,  of  the  male  prostate. 

3.  Abnormal  relics  of  the  Wolffian  body  at  the  liilum  of  the  ovary, 
and  in  the  broad  ligaments,  may  give  rise  to  papillomatous  develop- 
ments. Home  authors,  however,  consider  the  germ  epithelium  as  more 
jjroV)aVjly  the  source  of  those  when  they  are  y)resent  in  the  ovary. 

4.  Partner's  canal  may  give  rise  to  broad  ligament,  uterine,  and 
vaginal  cysts. 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN   WOMAN     63 

5.  Malformations  are  really  due  to  persistent  stages  of  arrested 
development. 

D.  Bekry  Hakt. 
REFERENCES 

The  following  references  do  not  represent  Gynaecological  Anatomy,  but  merely  the 
main  sources  used  in  this  sketch.  Fuller  sources  are  indicated,  and  should  be  con- 
sulted when  necessary. 

1.  CuLLiNGwoRTH.  "  A  Note  ou  the  Anatomy  of  the  Hymen  and  that  of  the 
Posterior  Commissure  of  the  Vulva,"  Jour,  of  Anat.  and  Phys.  vol.  xxvii.  p.  343. — 2. 
Farre.  "Uterus  and  its  Appendages,"  Encyc.  of  Anat.  and  Phys.  vol.  v.  Supjjt. — 
3.  Flower.  Nerves  of  the  Human  Body.  London,  1872.  —  4.  Frankenhaeuser.  Die 
Nerven  der  Gebaer mutter.  Jena,  18(J7. — 5.  Gawronsky,  V.  "  Ueber  Verbreitung  and 
Endigung  der  Nerven  in  den  weiblichen  Genitalien,"  Ai-ch.  fur  Gyn.  Bd.  xlvii.  S.  271. 
—  6.  Hart.  Atlas  of  Female  Pelvic  Anatomy.  Edin.  1884.  —  7.  Ihid.  Contributions 
to  the  Sectional  Anatomy  of  the  Female  Pelvis.  Edin.  188.5.  —  8.  Head.  "On  Dis- 
turbance of  Sensation  with  Special  Reference  to  the  Pain  of  Visceral  Disease,"  Brain, 
1893. — 9.  Herman.  "A  Contribution  to  the  Anatomy  of  the  Pelvic  Floor,"  Trans. 
Loud.  Obst.  Soc.  vol.  xxxi.  — 10.  Henke.  Topographische  Anatomic  des  Menschen. 
Berlin,  1879.  — 11.  Hyrtl.  Die  Corrosions  Anatomic  und  ihre  Ergehnisse.  Wien, 
1873.— 12.  Klein.  "Entstehung  des  Hymen,"  Festschrift  der  Gesellschaft  fiir  Geb. 
und  Gyn.  in  Berlin.  Wien,  1894.  — 13.  Minot.  Human  Embryology.  New  York, 
1892.  — 14  Sutton,  J.  B.  Surgical  Diseases  of  Ovary.  London  and  New  York.  —  l.'i. 
Waldeyer.  Beitrdge  zur  Kenntniss  der  Lage  der  iveiblichen  Beckenorgane.  Bonn, 
1892.    For  a  fuller  record  of  literature  see  Hart's  Atlas  and  Index  MedicUs. 

D.  B.  H. 


MALFORMATIONS   OP  THE  GENITAL  ORGANS  IN  WOMAN 

Introduction.  —  The  malformations  of  the  female  genital  organs  form  a 
natural  and  sharply  defined  group  of  deformities  whose  special  interest, 
from  the  gynaecological  standpoint,  lies  in  the  effects  which  they  produce 
upon  the  menstrual  phenomena,  and  upon  the  sexual  and  reproductive 
life  of  the  woman  in  whom  they  exist.  These  effects  vary  greatly  in 
importance  with  the  nature,  position,  and  extent  of  the  malformation  ; 
and  also,  doubtless,  with  the  constitution  of  the  patient  and  her  condi- 
tion as  regards  marriage.  INIanifestly  the  absence  of  the  uterus  is  a 
more  serious  matter  than  the  imperfect  development  of  an  ovary  or  a 
tube ;  and  malformations  which  are  of  grave  import  in  a  married  woman 
may  exist  without  inconvenience  in  a  spinster. 

It  will  be  convenient  to  consider,  first,  the  malformations  of  indi- 
vidual organs,  beginning  with  those  of  the  ovaries,  and  dealing  in  turn 
with  the  Fallopian  tubes,  uterus,  vagina,  and  vulva;  I  shall  tlien  dis- 
cuss the  abnormalities  which  affect  more  than  one  of  the  reproductive 
organs,  including  cases  of  '"  hermaphroditism." 

In  studying  these  genital  anomalies,  it  must  not  be  forgotten  that 
we  are  concerned  with  organs  which  are  derived  from  at  least  three 
distinct  sets  of  embryonic  structures.  As  embryology  is  the  true  key 
to  the  understanding  of  the  nature  of  malformations,  it  will  be  well  to 
state  shortly  what  these  organs  and  structures  are. 


64  SVSTEJ/  OF  GYNECOLOGY 

Developmext  of  the  Female  Genital  Organs.  —  i.    The  Ovaries. 

—  lu  the  early,  sexually  indifferent  embryo  a  development  of  certain 
cells  of  the  genital  fold  or  ridge  takes  place  on  each  side  of  the 
vertebral  column  in  the  lumbar  region.  These  cells  of  the  germinal 
epithelium,  for  that  is  the  name  given  to  the  epithelium  of  the  peri- 
toneum in  this  region,  form  the  genital  or  sexual  glands  which  develop 
at  a  later  stage  into  the  ovaries  in  the  female  and  the  testicles  in  the 
male.  Only  a  part,  however,  of  the  genital  gland  is  thus  produced. 
In  the  female  this  part  of  the  ovary  contains  the  ova,  and  is  called  the 
oophoron ;  the  other  portion,  the  paroophoron  or  tubuliferous  portion, 
has  a  different  origin.  In  the  early  embryo  there  is  seen,  lying  to  the 
outer  side  of  the  genital  fold,  a  glandular  mass  —  the  mesonephros  or 
Wolffian  body,  with  a  duct — the  segmental  or  Wolffian  duct.  In  the 
male,  some  of  the  tubules  of  the  Wolffian  body  extend  into  the  genital 
gland,  and  form  the  rete  testis,  others  remain  as  the  vasa  efferentia, 
whilst  the  Wolffian  duct  becomes  the  epididymis  and  vas  deferens.  In 
the  female  the  Wolffian  body  largely  atrophies;  still,  just  as  in  the 
male,  some  of  its  tubules  enter  into  the  genital  gland,  and  form  the  par- 
oophoron, whilst  others,  along  with  the  Wolffian  duct,  persist  in  a  rudi- 
mentary state  as  the  parovarium  or  epoophoron,  and  occasionally  as 
Gartner's  duct.-^  At  a  later  stage  in  development  the  sexual  glands 
descend  from  their  primitive  position,  the  testicles  passing  to  the  scro- 
tum, and  the  ovaries  to  the  brim  of  the  true  pelvis.  Such  is  the  com- 
position and  development  of  the  ovary ;  and  the  anomalies  which  may 
be  expected  are,  therefore,  malposition  or  non-descent  of  the  whole 
organ,  and  abnormalities  by  excess  or  defect  of  either  or  both  its  con- 
stituent parts,  oophoron  and  paroophoron. 

2.  The  Fallopian  Tubes,  Uterus,  and  Vagina  are  the  representatives 
of  the  two  Miillerian  ducts  of  the  embryo.  Lying  near  the  Wolffian 
body,  and  on  the  outer  side  of  the  Wolffian  duct,  the  Miillerian  duct, 
which  is  at  lirst  a  solid  cord,  passes  downwards  to  open  into  the  allan- 
toic portion  of  the  cloaca.  At  a  later  stage  the  duct  acquires  a  lumen, 
and  later  still  it  fuses,  in  its  loAver  portion,  with  its  fellow  of  the  oppo- 
site side  to  form  the  uterus  and  vagina,  whilst  its  upper  part  remains 
separate  as  the  Fallopian  tube.  In  the  male  foetus  the  Miillerian  ducts 
atrophy  almost  entirely,  and  are  represented  only  by  the  uterus  mascu- 
linus  or  prostatic  vesicle,  and  jjossibly  by  the  true  hydatid  of  Morgagni. 
The  anomalies  that  may  be  expected  in  connection  with  these  organs  in 
the  female  are  ii'regularities  in  the  fusion  of  the  lower  parts  of  the 
Miillerian  ducts,  in  their  mode  of  termination,  their  partial  or  complete 
absence,  and  their  imperforate  condition.  As  will  be  seen  later,  all  these 
malformations  (that  is,  double  uterus  and  vagina,  uterus  unicornis,  atresia 
and  defectus  uteri  et  vaginae,  and  so  forth),  and  others  which  are  not  so 
easily  explained  by  the  help  of  embryology,  are  comparatively  common. 

3.  The  Vulva.  —  The  mode  of  development  of  the  external  organs  of 
generation  is  more  complicated  than,  and  not  so  well  understood  as  that 

1  For  fiirllier  iiifonnutioii  011  tho  lioiiiolo;^ios  of  these  structures,  see  (1). 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN   WOMAN     65 

of  the  vagina  and  uterus  with  its  annexa.  At  the  posterior  or  lower  end 
of  the  embryo  an  invagination  of  the  ectoderm  occurs,  by  which  the 
cloaca  is  brought  into  communication  with  the  exterior,  and  thus  is 
formed  the  cloacal  opening  or  primitive  anus.  This  is  followed  by  an 
indifferent  stage,  during  which  it  is  impossible  to  foretell  the  sex  of  the 
embryo.  The  anterior  part  of  the  anal  plate  becomes  thickened,  and 
gives  rise  to  a  projection  known  as  the  genital  tubercle,  which  is  the  an- 
lage  of  the  penis  in  the  male,  and  of  the  clitoris  and  nymphse  in  the 
female.  In  its  inditferent  stage  it  may  be  termed  the  phallus.  On  the 
under  surface  of  the  genital  tubercle  appears  a  groove  —  the  genital 
groove  —  which  passes  backwards  into  the  cloaca.  In  the  female  the 
lips  of  this  furrow  become  the  labia  minora,  and  the  integument  outside 
them  develops  into  the  labia  majora.  Soon  the  cloaca  is  seen  to  be 
divided  by  a  partition  —  the  future  perineum  —  into  an  anterior  cavity, 
or  uro-genital  sinus,  into  which  open  the  uiinary  and  sexual  ducts,  and 
a  posterior  which  opens  at  the  permanent  anus.  In  the  female  the 
genital  tubercle  remains  small  and  imperforate,  and  the  sinus  urogeni- 
talis  persists  as  the  vestibule  into  which  opens  the  urethra  (the  drawn- 
out  lower  end  of  the  allantois),  and  the  vagina  with  its  hymeneal  fold. 

From  what  has  been  said  of  the  development  of  the  external  genitals, 
complicated  as  it  is  with  that  of  the  lower  end  of  the  bowel  and  uro- 
genital ducts,  it  is  not  difficult  to  understand  how  many  puzzling  anoma- 
lies may  arise,  —  anomalies  which  have  led  to  errors  in  the  determination 
of  the  sex  of  the  infant  at  birth,  and  to  most  unhappy  consequences  in 
later  life.  One  is,  therefore,  prepared  to  find  that  the  principal  mal- 
formation of  the  external  genitals  is  that  known  as  hermaphroditism, 
or  by  the  better  name  of  pseudo-hermaphroditism. 

The  mode  of  development  of  the  generative  organs  must  be  constantly 
borne  in  mind  in  the  study  of  the  malformations  to  which  they  are  sub- 
ject ;  for  many  of  these  are  thus  at  once  capable  of  explanation.  Cer- 
tain anomalies,  it  is  true,  admit  of  no  such  easy  elucidation ;  nevertheless 
it  is  probable  that  a  more  exact  knowledge  of  the  early  stages  of  devel- 
opment, Avhen  obtained,  will  serve  to  clear  up  what  is  at  present  obsciire. 
The  primary  etiological  factor  which  interferes  with,  and  arrests  the 
development  of  the  internal  genital  organs,  may  with  some  confidence 
be  supposed  to  be  foetal  peritonitis.  The  malformations  of  the  external 
parts  may,  on  the  other  hand,  be  due  to  amniotic  compression  or  adhesion. 

Malformatioxs  of  the  Ovaries.  —  It  is  only  Avithin  recent  years 
that  special  attention  has  been  paid  to  ovarian  anomalies,  yet  these  dis- 
orders affect  the  sexual  life  and  responsibilities  of  the  woman,  and  may  in- 
terfere with  the  success  of  such  operations  as  oophorectomy  or  ovariotomy. 

Pathology.  —  1.  Supernumevavyj  Ovaries.  —  It  is  Avell  to  reserve  the 
term  "  supernumerary  ovary  "  for  such  rare  cases  as  that  reported  by 
Winckel,  in  which  a  third  ovary  lay  in  front  of  the  uterus,  to  which  it 
was  attached  by  a  strong  ovarian  ligament.  It  also  formed  connections 
with  the  bladder  and  with  the  right  Fallopian  tube.     The  two  normal 

F 


66  SYSTEM  OF  GYNECOLOGY 

ovaries  were  of  equal  size,  and  there  were  no  traces  of  peritonitis  in 
their  neighbourhood.  The  supernumerary  ovary  was  twice  the  natu- 
ral size.  The  patient,  an  old  woman,  was  sterile,  notwithstanding  the 
abundance  of  ovarian  tissue.  No  case  exactly  resembling  Winckel's 
has  yet  been  recorded,  and  the  condition  must  be  very  rare.  Embry- 
ology gives  little  help  in  solving  its  mode  of  origin.  It  may  have  been 
due  to  duplication  of  the  sexual  gland  on  one  side ;  but  Winckel  sug- 
gests that  it  was  developed  from  the  anlage  of  the  bladder  (allantois), 
and  that  in  this  way  its  vesical  attachment  is  explicable. 

2.  Accessory  or  Constricted  Ovaries.  — Accessory  ovaries  differ  greatly 
from  the  anomaly  which  has  just  been  described.  They  are  much  less 
rare,  for  they  are  found  in  from  two  to  three  per  cent  of  autopsies ;  they 
are  rounded  bodies  always  smaller  than  the  normal  ovary,  to  which  they 
have  a  pediculated,  rarely  a  sessile  attachment  near  its  peritoneal  bor- 
der, and  they  vary  in  number  from  one  to  three.  In  a  case  observed  by 
J.  D.  Williams,  and  seen  by  myself,  the  accessory  ovary  was  of  the  size 
of  a  large  pea;  it  was  made  up  of  ovarian  stroma  with  Graafian  folli- 
cles, and  was  attached  to  the  anterior  border  of  the  right  ovary  by  a 
stalk  which  consisted  partly  of  fibrous  tissue,  with  an  external  coating 
of  low  cubical  epithelium,  and  partly  of  solid  columns  of  epithelial  cells 
enclosed  in  the  fibrous  tissue.  In  the  above  case  there  had  been  dehis- 
cence of  at  least  one  Graafian  follicle,  for  a  cicatrix  was  found.  An 
accessory  ovary  may  become  cystic.  Mr.  Doran  has  pointed  out  that 
small  fibromyomas  may  arise  in  the  ovarian  ligament,  and  be  mistaken 
for  accessory  ovaries ;  but  in  most  of  the  recorded  cases  there  seems  to 
have  been  little  doubt  of  the  glandular  character  of  the  bodies. 

Accessory  ovaries  are  probably  constricted  portions  of  the  normal 
organ  which  have  been  separated  at  an  early  period  in  the  development, 
])0ssibly  by  the  agency  of  foetal  peritonitis ;  in  rare  cases  the  ovary  has 
even  been  found  divided  into  two  nearly  eqiial  parts  by  such  a  constric- 
tion. At  the  same  time  traces  of  peritonitis  are  not  always  present, 
and  then  it  is  possible  that  the  accessory  glands  were  produced  by  a 
form  of  budding  of  the  primitive  sexual  gland.  This  latter  hypothesis 
is  strengthened  by  the  fact  that  in  some  instances  the  accessory  ovary 
consisted  entirely  of  Pflilger's  tubes.  It  is  also  possible  that  cases  of 
this  kind  may  have  given  rise  to  the  notion  that  both  ovary  and  testicle 
were  present  in  the  same  individual,  the  accessory  ovary  with  its  tubu- 
liferous  structure  being  i-egarded  as  a  testicle. 

3.  Hypertrophy  of  the  Ovary.  —  Occasionally  ovaries  of  twice  the  nor- 
mal size  have  been  found  in  the  infant  at  l)irth.  This  may  be  due  to 
liyperplasia  of  all  the  component  parts  of  tlie  gland ;  or  to  an  increase 
in  tlie  connective  tissue  elements  with  destruction  of  the  Graafian  fol- 
licles, the  result  possibly  of  f«;tal  oophoritis.  In  twin-bearing  women 
the  ovaries,  according  t(j  Ilellin,  (;ontiiin  an  unusually  largo  number  of 
ovisacs,  a  persistence,  in  fact,  of  the  fa;tal  character  of  the  glands. 

4.  Absence  of  the  Ovaries.  —  Complete  absence  of  both  ovaries,  save 
in  sympodial  and  acephalic  foetuses,  is  an  exceedingly  rare  anomaly.    It 


MALFORMATIONS    OF   THE    GENITAL    ORGANS   JN    IV OMAN     67 

can  only  be  absolutely  proven  by  a  post-mortem  examination  of  both 
pelvis  and  abdomen ;  for  the  glands  may  exist  in  a  rudimentary  state, 
or  in  an  unusual  position,  and  so  escape  notice  clinically. 

Absence  of  one  ovary  is  also  a  rare  defect,  but  its  occurrence  is  well 
established.  It  is  usually,  but  not  invariably  associated  with  absence  of 
the  corresponding  half  of  the  uterus  {u.  unicnrnis),  and  of  the  tube  of 
the  same  side ;  one  kidney  is  also  wanting  in  certain  cases.  It  would 
seem,  therefore,  that  defect  of  the  sexual  gland  is  apt  to  carry  with  it 
absence  of  the  Mlillerian  and  segmental  ducts  and  Wolffian  body. 

5.  Rudimentary  State  of  the  Ovaries.  —  This  is  much  less  rare  than 
complete  absence  of  one  or  both  ovaries.  The  glands  are  small  in  size 
and  have  either  the  foetal  or  the  adult  form.  Microscopically  they  may 
show  no  Graafian  vesicles ;  they  may  consist  simply  of  connective  tis- 
sue, with  vessels  and  scanty  muscular  fibres,  or  they  may  exhibit  a  few 
ill-developed  ovisacs  in  the  midst  of  ovarian  stroma.  Sometimes,  by 
the  persistence  of  Pfltlger's  tubes  in  an  unclosed  state,  they  may  simu- 
late testicles.  They  may  occupy  their  normal  position  ;  or,  as  in  Blot's 
case,  they  may  lie  near  the  upper  angle  of  the  uterus ;  or,  again,  they 
may  be  found  herniated  in  the  inguinal  canal.  They  may  coexist  with 
accessory  ovaries,  with  rudimentary  Fallopian  tubes,  with  a  bifid  or 
foetal  uterus,  and  with  stenosis  of  the  aorta.  At  the  same  time  the 
uterus  may  be  normal,  and  the  ovaries  rudimentary  and  conversely. 
Such  defects  in  ovarian  development  may  be  due  to  fostal  oophoritis 
or  peritonitis,  or  to  torsion  of  the  pedicle  of  the  gland. 

6.  Displacement  of  the  Ovaries.  —  Kon-descent  of  an  ovary  is  a  rare 
but  not  unknown  anomaly.  ]\Ir.  Bland  Sutton  has  reported  a  case  in 
which  the  right  ovary  was  adherent  to  the  lower  border  of  the  kidney 
of  the  same  side,  and  I  have  seen  a  case  in  the  new-born  infant  in 
which  it  was  attached  by  peritonitic  bands  to  the  caecum.  It  has  been 
stated  that  it  may  be  found  free  in  the  peritoneal  cavity,  or  adherent 
to  the  omentum ;  it  may  then  be  cystic. 

Instead  of  non-descent,  there  may  be  dislocation  of  the  ovary  down- 
wards into  the  inguinal  canal.  According  to  Puech,  congenital  inguinal 
hernia  of  the  ovary  is  much  more  common  than  acquired,  and  Zinnis 
has  recently  reported  an  instance  of  it;  but  Bland  Sutton  states  that 
he  knows  of  no  case  in  which  the  ovarian  nature  of  the  herniated  body 
has  been  proved  by  microscopical  examination  conducted  by  a  compe- 
tent observer.  Herniation  of  the  ovary,  Avhich  may  be  unilateral  or 
bilateral,  is  usually  associated  with  displacement  of  the  Fallopian  tube, 
and  sometimes  with  malformation  of  the  uterus  and  mali)osition  of  tlie 
kidney.  It  may  be  due  to  defective  development  of  the  round  ligament 
and  a  patent  condition  of  the  canal  of  Nuck.  A  congenital  crural,  ova- 
rian hernia  has  not  yet  been  observed. 

Clinical  Features.  — The  presence  of  supernumerari/ov  accessor}/  ovaries 
is  no  guarantee  of  fortility ;  for  in  certain  of  the  recorded  cases  the  pa- 
tients, although  married,  had  not  borne  children.  The  woman  seen  by 
Olshausen,  however,  had   had  three  confinements.     Sterility  in  these 


68  SYSTEM  OF  GYNECOLOGY 

cases  is  to  be  accounted  for  by  the  cystic  or  atrophic  state  in  which 
the  ovaries,  both  normal  and  accessory,  are  often  found ;  and  possibly 
the  foetal  peritonitis,  which  caused  the  division  of  the  gland,  led  also 
to  destruction  of  the  ovisacs  in  it.  In  another  direction,  however,  ac- 
cessory ovaries  have  a  certain  clinical  importance ;  their  presence  may 
explain  the  occasional  persistence  of  menstruation  after  double  ovari- 
otomy or  oophorectomy,  as  has  been  pointed  out  by  Homans  and  others  ; 
the  removal  of  three  entirely  separate  ovarian  cystomata  or  dermoids 
is  rendered  possible,  as  in  Sippel's  case ;  and  the  occurrence  of  iDreg- 
nancy  after  a  double  ovariotomy  finds  a  very  probable  explanation. 
Their  diagnosis  must  always  be  a  matter  of  great  difficulty ;  but  their 
occasional  presence  must  be  borne  in  mind  when  small  bodies  are  felt 
in  the  pelvis  near  to,  or  even  at  some  distance  from  the  normal  ovaries. 

The  clinical  importance  of  absence  or  of  a  rudimentary  state  of  the 
ovaries  depends  greatly  on  the  unilateral  or  bilateral  character  of  the 
anomaly.  If  only  one  ovary  be  absent  there  may  be  no  interference 
with  the  patient's  reproductive  power;  for  in  the  case  reported  by 
Busch,  and  quoted  by  Lawson  Tait,  the  woman,  notwithstanding  uni- 
lateral absence  of  tul3e  and  ovary,  had  borne  ten  children.  When,  on 
the  other  hand,  both  ovaries  are  wanting  or  imperfect,  indications  of 
the  defect  are  usually  forthcoming  at  the  time  of  puberty.  Then  there 
is  an  absence  of  the  changes  peculiar  to  this  age,  such  as  the  establish- 
ment of  the  menstrual  flow,  the  growth  of  hair  on  the  mons  veneris, 
and  a  rounding  of  the  figure ;  the  individual  approximates  rather  to 
the  male  than  to  the  female  type,  or  possibly  retains  the  characters  of 
infancy,  with  or  without  idiocy  or  cretinism.  Exceptions  occur,  hoAV- 
ever,  in  which  the  woman  shows  the  normal  female  character  and  has 
.active  sexual  desire.  Epilepsy  may  occasionally  appear  at  the  period 
of  puberty ;  Skene  believes  that  defective  development  of  the  ovaries 
is  of  importance  as  a  cause  of  mental  weakness,  and  even  of  insanity, 
•for  normally  the  brain  is  stimulated  to  higher  development  by  the 
demands  of  these  organs.  There  would  seem  also  to  be  more  than  an 
accidental  connection  between  chlorosis  and  imperfectly  formed  ovaries. 
In  adult  life  sterility  is  the  constant  result  of  a  bilateral  absence  of  the 
sexual  glands ;  and  it  may  be  accompanied  by  the  growth  of  hair  on 
the  face,  and  especially  on  the  upper  lip. 

Jt  is  extremely  difficult,  if  not  impossible,  to  determine  during  life 
the  existence  of  the  ovarian  defects  under  consideration  :  vaginal,  rectal, 
and  vesical  touch,  even  when  combined  with  abdominal  palpation,  often 
fail  to  establish  a  sure  diagnosis ;  and  nothing  short  of  laparotomy  gives 
certainty.  Yet  it  is  very  important  that  the  anomaly  should  be  detected, 
or  at  least  suspected,  if  only  to  save  the  pati(!nt  and  her  medical  at- 
tendant from  the  dissatisfaction  and  disa])pointment  consequent  upon 
the  employment  of  a  long  anrl  futile  course  of  treatment  for  the  es- 
tablishment of  menstruation  by  means  of  stem  pessaries  and  the  like. 
Even  when  fairly  conclusive  evidence  of  the  rudimentary  state  of  the 
ovaries  exists  it,is  by  no  means  certain  that  the  lesion  is  truly  congenital, 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN   WOMAN     69 

for  scarlet  fever  and  other  zymotic  affections  occurring  in  childhood 
may  lead  to  their  injury. 

Ovarian  hernia  is  suggested  by  the  presence  of  a  rounded  or  oval 
body  in  the  inguinal  canal  or  lalDium  majus,  whether  on  one  or  both 
sides,  Avhen  it  occurs  in  an  individual  with  a  uterus  and  external  genitals 
of  the  female  type.  For  a  certain  diagnosis  of  the  displaced  gland 
microscopical  examination  is  necessary,  but  the  absence  of  the  ovary 
from  its  normal  position  in  the  pelvis  as  determined  by  bimanual  ex- 
amination, the  enlargement  of  the  herniated  body  at  the  menstrual 
periods,  and  the  existence  of  dysmenorrhoea  and  dyspareunia,  usually 
justify  the  provisional  diagnosis  of  inguinal  ovarian  displacement.  It 
must  be  borne  in  mind  that  the  dislocated  gland  may  undergo  cystic 
changes  which  will  mask  its  true  nature.  AVith  regard  to  treatment, 
attempts  at  reduction  almost  invariably  fail ;  and  palliative  measures, 
such  as  wearing  a  hollow  pad  over  the  ovary,  are  rather  indicated. 
When  the  gland  becomes  inflamed  or  cystic,  ovariotomy  will  be  neces- 
sary;  but  when  it  is  healthy  it  ought  not  to  be  removed,  for  pregnancy 
has  been  known  to  occur  even  with  double  ovarian  hernia. 

Malformatioxs  of  the  Fallopiax  Tubes.  —  Since  it  has  become 
customary  to  perform  abdominal  section  for  the  relief  of  various 
morbid  states  of  the  viscera,  attention  has  been  more  specially  directed 
to  the  study  of  the  malformations  of  the  Fallopian  tubes;  and  it 
is  now  known  that  these  ducts  may  exhibit  many  anomalies  with  some 
of  which  earlier  writers  were  unacquainted.  The  exact  bearing  of  these 
abnornuxlities  upon  the  physiology  and  pathology  of  reproduction  is  not 
fully  determined  ;  but  there  is  reason  to  believe  that  ectopic  pregnancy 
may,  in  some  instances  at  least,  be  due  to  developmental  errors  in  the 
tubes.  Tulml  anomalies,  like  those  of  ovaries,  may  be  roughly  classified  into 
those  of  excessive  formation,  those  of  defect,  and  those  of  altered  rela- 
tion.   These  terms,  however,  must  not  be  taken  in  a  strictly  literal  sense. 

Pathology.  — 1.  Supernumerary  Fallopian  Tubes.  —  Examples  of  com- 
plete duplication  of  the  tube,  like  genuine  cases  of  supernumerary  ovary, 
are  extremely  rare ;  the  two  conditions  may  be  associated.  Instances 
have  been  reported  by  Keppler,  Falk,  and  Kuppolt;  the  last  named 
author  was  of  opinion  that  in  his  case  the  tube  and  ovary  had  been 
divided  into  two  parts  by  the  action  of  fatal  peritonitis. 

2.  Accessory  Tubal  Ostia  and  Tubes. — Another  tubal  malformation, 
which  may  be  reckoned  among  those  '•'  by  excess,"  is  the  presence  of 
accessory  ostia  or  tubes.  Opinions  vary  as  to  their  frequency ;  Eichard 
found  them  as  often  as  five  times  in  thirty  cases;  Kossmann  noted  them  in 
from  4  to  10  per  cent ;  and  J.  D.  Williams  and  the  present  writer  observed 
two  examples  in  sixty-one  consecutive  autopsies  (Fig.  31).  From  .3  to  C) 
per  cent  is  doubtless  the  usual  proportion.  Until  recently  more  than 
three  accessory  ostia  on  one  tube  had  not  been  observed,  and  commonly 
there  are  one  or  two  only ;  but  Ferraresi  has  put  on  record  a  remarkable 
case   in  which  there  were  six.     The  ostia  are  either  sessile  or  have 


70 


SYSTEM  OF  GYNECOLOGY 


pedicles  consisting  of  accessory  tubes ;  they  are  usually  surrounded 
by  finibrite.  They  are  generally  situated  near  the  normal  abdominal 
opening,  and  on  the  upper  convex  border  of  the  tube  ;  but  sometimes 
they  lie  midway  between  the  normal  ostium  and  the  uterine  end  of  the 
oviduct.  -Usually  they  communicate  Avitli  the  tubal  lumen.  Doran 
explains  the  origin  of  accessory  ostia  by  partial  failure  in  the  closure  of 
the  groove  in  the  germinal  epithelium  which  forms  the  upper  part  of  the 
!Milllerian  duct ;  at  the  same  time  he  thinks  that  they  may  also  be  due 
to  splitting  along  the  outer  edge  of  Mtiller's  duct  after  it  has  formed  a 
closed  tube.     Kossmann,  however,  believes  that  they  are  occasioned  by 


Fig.  81. — Anterior  view  of  right  uterine  appendages,  showing  accessory  abdominal  ostium  of  tube. 
A,  Uterus  ;  B,  cut  surface  of  mesovarium  ;  C,  right  Fallopian  tube  ;  D,  fimbriated  extremitj' ;  K, 
accessory  ostium  abdominale  ;  F,  free  fold  of  anterior  layer  of  mesosalpinx  ;  G,  pedunculated  cyst; 
H,  right  ovary. 

the  existence  of  a  supernumerary  embryonic  "anlage  "  (rudiment),  lying 
parallel  to  the  primary  one. 

3.  Tubal  Appendages  or  Accessory  Fimbrice.  —  Ferraresi  gives  the 
name  tuVjal  appendages  ("appendici  tube")  to  certain  structures,  not  un- 
commonly met  with,  which  may  be  identified  with  the  "  pedunculated 
tufts  of  fimbrise"  described  l)y  P>land  Sutton.  Superficially  they  boar  a 
resemblance  to  accessory  ostia,  l)ut  their  stalk  is  solid,  and  they  show  no 
ostium.  Ferraresi  found  them  six  times  in  forty  cases,  and  when  present 
they  occupy  the  same  positions  as  accessory  ostia ;  two  have  been  seen 
on  the  same  tube.  Bland  Sutton  regards  them  as  ruptured  cysts  of 
Kobelt's  tubes  ;  but  more  proljably  they  have  the  same  origin  as  the 
accessory  fimbriated  ostia. 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN    WOMAN     71 

4.  Anomalies  in  the  Length  of  the  Tubes.  —  In  cases  of  ovarian  hernia 
the  tube  has  often  an  unusual  length.  Even  when  there  is  no  such 
displacement  it  may  attain  abnormal  dimensions  — 16  to  17  cms.  in 
length  according  to  Sinety.  The  normal  length  is  from  10  to  11  cms., 
and  the  longest  tube  met  with  by  J.  D.  Williams  and  myself  meas- 
ured 14  cms. 

The  tubes  may  also  be  of  unequal  length  —  sometimes  the  right, 
and  at  other  times  the  left  being  the  longer.  Winckel  says  with  regard 
to  primary  or  congenital  inequalities,  that  the  embryonal  causes  may  be 
an  unequal  length  of  the  "  anlage,"  irregular  position,  restricted  motion 
from  the  pressure  of  neighbouring  organs,  or  increased  traction  from 
foetal  peritonitis. 

5.  Absence  of  the  Fallopian  Tube.  —  Absence  of  the  tubes  may  be 


Fig.  .32.  —  Congenital  absence  of  outer  two-thirds  of  riglit  Fallopian  tube.  (Post,  view.)  A,  Fundus 
uteri;  B,  B,  tubercular  nodules  in  isthmus  of  each  Fallopian  tube;  C,  parovarian  cyst;  D,  D, 
ovaries  ;  E,  cone-like  end  of  right  Fallopian  tube,  outer  two-thirds  being  absent ;  F,  cut  margin  of 
right  mesosalpinx  ;  H,  tibroma  of  right  ovary  ;  k,  adhesions  on  posterior  wall  of  uterus. 

bilateral ;  but  more  frequently  one  only  is  Avanting.  In  the  former  case 
the  defect  is  usually  associated  with  absence  of  the  uterus ;  whilst  in  the 
latter  the  uterus  unicornis  is  commonly  present,  the  absent  uterine  horn 
being  on  the  same  side  as  the  absent  tube.  Colomiatti,  however,  has 
reported  a  case  in  which  the  vagina  and  uterus  were  well  formed,  and  yet 
the  right  tube  and  ovary  were  absent.  Unilateral  defect  of  the  tube 
usually  carries  with  it  absence  of  the  ovary ;  but  this  is  not  invariable, 
for  in  Blot's  specimen  the  gland  was  present  but  rudimentary.  In  cer- 
tain instances  the  corresponding  kidney  is  also  wanting.  The  want  of 
development  of  the  upper  part  of  ^Miiller's  duct  is  doubtless  the  cause  of  the 
anomaly ;  Avhen  the  whole  duct  is  absent  there  is  also  a  unicornate  uterus. 
G.  Rudimentary  State  of  the  Tubes.  —  In  rare  cases  the  outer  part  of 
the  tube  is  absent ;  thus,  in  a  case  of  genital  tuberculosis,  J.  D.  Williams 
and  the  writer  noted  congenital  absence  of  the  outer  two-thirds  of  the 
right  oviduct,  the  inner  third  having  a  lumen  and  tapering  to  a  point  at 
its  outer  end  (Fig.  32).  In  a  post-mortem  room  specimen  Sir  T.  Grainger 
Stewart  observed  that  the  tubes  were  shorter  than  normal,  ended  blindly, 
and  were  connected  by  bands  with  the  peritoneum  covering  the  rectum. 
Absence  of  the  outer  part  of  the  tube  does  not  necessarily  carry  with  it 
defect  of  the  corresponding  ovary ;  but  in  the  case  seen  by  IMarchand  it 


72  SYSTEM   OF  GYNECOLOGY 

did  so.  Doubtless  the  anomaly  is  due  to  foetal  peritonitis.  Sometimes 
only  the  fimbriae  of  the  ostium  abdominale  are  wanting. 

Partial  or  complete  absence  of  the  normal  tunnelling  of  the  tubes 
may  be  met  with ;  and  then  these  organs  are  represented  by  solid  cords 
of  fibrous  or  muscular  tissue.  Sometimes  it  is  at  the  abdominal  end  only 
that  the  tube  is  imperforate :  in  the  case  described  by  Dr.  Haultain  the 
outer  extremity  of  one  tube  was  quite  smooth,  like  the  finger  of  a  glove ; 
the  tubal  mucosa  showed  no  folds,  and  the  ovary  on  the  same  side  was 
cirrhotic  and  cystic.  Absence  of  the  tubal  lumen  is  simply  the  persistence 
of  the  normal  condition  of  the  embryo ;  Avhilst  an  imperforate  state  of  the 
ostium  abdominale  must  be  due  to  want  of  development  of  the  Miillerian 
funnel  which  should  open  into  the  splanchnocele. 

During  foetal  life  the  tubes  normally  exhibit  spiral  convolutions  both 
in  the  isthmus  and  ampulla ;  at  birth  these  have  disappeared  in  the 
isthmus,  and  in  the  adult  they  ought  to  be  entirely  absent.  Sometimes, 
however,  the  convolutions  persist,  as  in  some  of  the  specimens  described 
by  Popoft' ;  but  Haultain  is  of  opinion  that  tubal  contortion  in  the  adult 
is  more  commonly  due  to  a  return  to  the  foetal  state  than  to  a  persistence 
of  it.  If  endosalpingitis  occur  in  such  a  tube  it  is  easy  to  understand 
how  hydrosalpinx  or  pyosalpinx  may  be  initiated. 

7.  Displacemeyit  of  the  Tubes.  —  It  is  stated  that  the  tubes  may  show 
an  unusually  low  implantation  into  the  uterus  —  a  misplacement  which 
has  been  regarded  as  one  of  the  causes  of  placenta  praevia.  Displacement 
of  the  tubes  in  various  directions  may  be  the  result  of  foetal  peritonitis, 
as  in  a  specimen  shown  by  myself  to  the  Edinburgh  Obstetrical  Society ; 
and  in  cases  of  ovarian  hernia  the  tube  usually  accompanies  the  gland. 
A  curious  case  of  backward  dislocation  of  the  tubes,  with  union  of 
their  abdominal  ostia  to  form  a  ring  behind  the  uterus,  was  reported 
by  Hliter ;  but  some  doubt  existed  as  to  the  congenital  nature  of  the 
anomaly. 

8.  Tlie  Hydatid  of  Morrjagyd.  — This  name  is  often  loosely  applied  to 
pedunculated  cysts  arising  from  the  curved  tubules  of  Kobelt  (parova- 
rium), or  to  stalked  terminal  cysts  of  G-artner's  duct ;  but  it  ought  to  be 
reserved  for  the  much  less  common  cyst  which  is  found  attached  by 
a  pedicle  to  the  tube  or  to  its  fimbriae.  J.  D.  Williams  and  myself  met 
with  it  in  8  per  cent  of  the  adult  cases  examined  by  us ;  it  varies  in  size 
from  that  of  a  pea  to  a  small  bean ;  it  is  lined  by  a  mucosa  with  simple 
folds  covered  by  a  single  layer  of  ciliated  columnar  epithelial  cells ;  its 
wall  is  always  composed  of  muscular  fibres  arranged  circularly  and 
longitiulinally ;  its  outer  membrane  is  the  peritoneum;  its  stalk  is 
always  muscular;  and  its  contents  are  clear,  limpid  fluid.  Thus  it  may 
be  distinguished  from  the  false  hydatids  of  Morgagni.  It  has  been 
regarded  as  tlio  remnant  of  the  upper  end  of  Miillor's  duct. 

Clinical  Features.  —  Malformations  of  the  Fallopian  tubes  are  sel- 
dom diagnosed  dviring  life.  Tliey  may  be  discovered  during  the  per- 
formance of  laparotomy,  or  their  existence  may  be  suspected  Avhen 
anomalies  of  the  uterus  or  ovaries  are  known  to  be  present;  but  the 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN   WOMAN     73 

symptoms  to  which  they  give  rise  are  not  distinctive,  and  the  physical 
signs  associated  with  them  are  most  difficult  of  recognition. 

Abaence  or  imperforate  condition  of  the  tubes,  if  bilateral,  will  be  the 
cause  of  sterility  ;  and  if  in  such  cases  the  ovaries  be  present,  the  rupture 
of  Graafian  follicles  and  the  discharge  of  ova  into  the  abdominal  cavity 
may  occur  at  menstrual  epochs,  with  the  consequent  formation  of  small 
hsematoceles  and  the  occurrence  of  localised  peritonitic  attacks.  Unilat- 
eral absence  or  imperf oration  is  not  a  bar  to  conception,  for  the  tube  of  the 
opposite  side  may  transmit  the  ovum  to  the  uterus.  Spirality  of  the 
tubes  or  displacement  may  be  causes  of  dysmenorrhoea  and  also  of  sterility. 
It  has  been  thought  that  an  accessory  ostium  may  be  a  factor  in  the  pro- 
duction of  ectopic  pregnancy  —  the  ovum  passing  into  the  tube  by  the 
normal  ostium,  becoming  impregnated,  and  passing  out  into  the  peritoneal 
cavity  by  the  accessory  orifice  —  but  there  is  no  proof  that  this  can 
happen.  On  the  other  hand,  Sanger  has  recently  shown  that  an  accessory 
ostium  may  serve  for  the  ovum,  as  a  means  of  access  to  the  tube  and 
uterus  when  the  normal  tubal  openings  are  closed  on  both  sides  by  in- 
flammatory processes. 

Malformations  of  the  Round  and  Broad  Ligaments.  —  Mal- 
formations of  the  round  ligament  are  occasionally  met  with,  but  they  have 
been  little  studied,  and  are  doubtless  commonly  associated  with  abnormal 
states  of  the  uterus,  tubes,  or  ovaries.  Persistence  of  the  canal  of 
Nuck,  in  which  the  ligament  lies,  gives  rise  to  hydrocele  in  the  woman. 
The  broad  ligaments,  like  the  round,  may  be  absent,  rudimentary,  or 
unequally  developed.  The  ligamenta  lata  also  may  be  congenitally  dis- 
placed ;  and  they  often  contain  within  their  folds  cysts  which  have  de- 
veloped in  the  mesonephric  relics  which  form  the  organ  of  Eosenmiiller 
or  parovarium. 

Malformations  of  the  Uterus.  —  Malformations  of  the  uterus 
form  a  large  and  interesting  group  of  genital  anomalies,  the  mode  of 
origin  and  clinical  manifestations  of  which  have  long  been  the  subject 
of  extended  investigations.  The  various  types  of  uterine  anomaly  are, 
therefore,  well  known  :  their  pathogenesis  is,  with  one  or  two  exceptions, 
agreed  upon,  and  their  influence  on  the  general  and  sexual  health  of  the 
individual  is,  to  a  large  extent,  understood.  Saint-Hilaire,  Kussmaul, 
Eiirst,  Lefort,  and  Klebs  have  all  by  their  researches  greatly  increased 
our  knowledge  of  uterine  malformations. 

Variolas  plans  of  classification  have  been  proposed,  of  which  that 
by  Livius  Fiirst  is  the  most  comjjlete  and  philosophical.  He  divided  all 
anomalies  of  the  uterus  into  three  groups,  according  to  the  period  of  intra- 
uterine life  in  which  they  were  produced  —  those  originating  between 
the  first  and  eighth  weeks,  those  between  the  eighth  and  twentieth,  and 
those  betAveen  the  twentieth  and  fortieth  weeks.  In  the  first  group  were 
partial  or  total  absence  of  the  uterus,  and  a  solid  or  partly  excavated 
condition  of  the  organ,  which  might  be  single,  double,  or  bicornate.  In 
the  second  group  were  certain  minor  nmlformations  characterised  by 


74  SYSTEM   OF   GYNAECOLOGY 

trifling  alterations  in  external  form,  and  by  the  presence  of  a  more  or 
less  marked  septum  internally.  The  third  group  contained  a  single 
variety,  th6  uterus  which  retained  its  fcetal  characters  so  far  as  the 
presence  of  rugae  and  the  disproportionate  size  of  cervix  as  compared 
"with  the  body  of  the  organ  were  concerned.  This  scheme,  although 
invaluable  to  the  teratologist,  deals  too  much  with  minor  details  for  the 
practical  purpose  of  the  gynaecologist.  It  will  be  convenient  simply  to 
divide  uterine  anomalies,  like  those  of  the  tubes  and  ovaries,  into  three 
groups :  those  in  which  there  is  apparent  excessive  formation,  those  in 
which  defect  is  the  leading  character,  and  those  which  show  altered  rela- 
tionship of  parts.  The  word  apparent  is  inserted,  because  that  which 
is  commonly  called  a  "  double  "  uterus  is  really  an  organ  the  two  compo- 
nent parts  of  which,  derived  from  the  two  Mullerian  ducts,  have  not  fused 
into  one.  It  will  be  well  to  study  together  the  pathology  and  symp- 
tomatology of  each  variety,  for  several  of  them  are  of  considerable 
interest  and  importance  from  the  gynaecological  standpoint. 

Uterus  Accessorius  and  Trifid  Uterus.  —  Pathology.  —  The  uterus 
accessorius  and  the  trifid  uterus  are  probably  the  rarest  anomalies  of  that 
organ  which  have  been  recorded.  In  1894  Hollander,  during  the  per- 
formance of  laparotomy,  found  a  second  uterus  lying  in  front  of  the 
normal  one,  between  it  and  the  bladder.  This  he  termed  a  ''  uterus 
accessorius."  The  normal  organ  was  supplied  with  normal  tubes  and 
ovaries,  had  the  round  ligaments  attached  to  it,  and  was  retroflexed. 
The  accessory  uterus  had  neither  annexa  nor  round  ligaments,  was 
anteverted,  and  contained  some  placental  tissue.  There  was  a  single 
cervix  with  two  orifices  separated  by  a  bridge  of  tissue.  Each  orifice 
communicated  with  the  interior  of  one  uterus.  In  a  similar  case,  observed 
clinically  by  Skene,  there  was  a  small  second  uterus  lying  in  front  of  the 
normal  one. 

Depage,  also  during  a  laparotomy,  found  a  still  more  complicated  and 
puzzling  uterine  anomaly,  which  he  termed  "trifid  uterus."  There  was 
a  Vjifid  uterus  with  a  single  cervix  and  two  internal  cervical  orifices ;  but 
there  was  also  found,  attached  to  the  cervix,  a  third  uterine  lobe  forming  a 
closed  sac  containing  altered  blood.    Blood  cysts  were  found  in  the  ovaries. 

It  is  difficult  to  offer  a  satisfactory  explanation  of  the  mode  of  origin 
of  these  two  malformations.  It  might  be  thought  that  in  the  case  of  the 
uterus  accessorius  we  had  to  do  with  a  uterus  didelphys  in  which  rotation 
had  brought  the  two  horns  into  an  antero-posterior  relation ;  but  this 
supposition  utterly  fails  to  explain  the  attachment  of  the  annexa  and 
round  ligaments  to  one  uterus.  The  most  feasible  explanation  of  both 
the  accessory  and  the  trifid  uterus  is  that  during  embryonic  life  a  diver- 
ticulum is  formed  from  one  of  the  Mullerian  ducts,  and  that  this  develops 
into  the  supplementary  organ.  If  this  be  so,  these  anomalies  fully  deserve 
to  be  called  malformations  "  by  excess,"  which  the  so-called  "  double  " 
uterus  does  not. 

CJlinical  Features.  —  Hollander's  patient  had  had  seven  labours,  and 
had  thrice  aborted,  once  with  twins,  at  the  fourth  month.     The  placental 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN    WOMAN     75 

tissue  was  found,  in  the  uterus  accessorius,  that  is,  in  the  organ  without 
annexa.  Skene's  patient  suffered  from  leucorrhoea  from  the  accessory 
uterus.  The  case  seen  by  Depage  was  in  a  young  immarried  girl ;  and  in 
this  instance,  as  well  as  in  that  of  Hollander,  an  entirely  erroneous 
diagnosis  was  made,  and  the  true  state  of  affairs  was  discovered  during 
laparotomy. 

Uterus  Didelphys.  —  Pathology.  —  The  uterus  didelphys  —  or,  as  it  has 


Fig.  S3.  —  uterus  didelphys.  (After  Eisenniann  and  Martin.)  a,  a.  Double  vajrinal  entrance;  h, 
urethral  opening  ;  c,  urethra ;  d,  d,  double  vagina  ;  e,  e,  double  cervical  orifice  ;  /' /,  double  cervix  ; 
g,  g,  double  uterine  body;  h,  h,  round  ligaments  ;  i,  i,  Fallopian  tubes;  k,  k,  ovaries. 

also  been  named,  "  diductus,"  "  duplex,"  or  "  separatus  "  —  exhibits  the 
maximum  degree  of  separation  of  the  two  laterally  placed  halves  whieli 
normally  fuse  into  the  single  uterus  (Fig.  33).  There  appear  to  be  two 
single  uteri  lying  side  by  side,  each,  however,  possessing  only  one  ovary, 
tube,  and  roi;nd  ligament.  There  may,  also,  be  complete  or  incomplete 
duplication  of  the  vagina  (septa  or  sxttsepta)  ;  or  that  canal  may  be  single 
(simple.v).  The  two  wombs  are  seldom  exactly  equal  in  size,  and  one  of 
them  may  be  imperforate,  a  condition  giving  rise  to  ha^matometra  at 


76 


SYSTE.V   OF  GYN.-ECOLOGY 


puberty.  Xot  iincomiuonly  this  uterine  malformation  is  associated  with 
deformities  of  neighbouring  parts,  such  as  ectopia  vesicae  and  atresia  ani. 
Among  the  causes  wliich  have  been  invoked  to  explain  the  want  of 
union  of  the  two  Mtillerian  ducts,  and  the  consequent  formation  of  the 
uterus  didelphys,  are  distension  of  the  allantois,  the  absence  of  closure 
of  the  anterior  abdominal  wall,  and  the  existence  of  adhesions  between 
the  rectum  and  bladder. 

Clinical  Features.  —  Since  it  is  impossible  clinically  to  separate  cases 
of  uterus  didelphys  from  those  of  uterus  bicornis,  it  will  be  convenient 
to  consider  the  symptomatology  of  the  two  malformations  together. 

Uterus  Bicornis.  —  Patholog)/. — A  much  commoner  malformation  is  the 
uterus  bicornis,  in  which  the  two  halves  or  horns  are  not  entirely  separate, 
as  in  the  didelphous  organ,  but  are  united  more  or  less  intimately  at  their 


Fig.  84.  —  Uterus  bicornis.  (After  Schroder  and  Martin.)  a,  a,  Tlie  vaginse,  laid  open;  b,  the  left 
cervix;  c,  the  cervix,  externally  apparently  single,  but  divided  into  two  internally;  d,  d,  the  two 
uterine  horns  ;  e,  e,  the  round  ligaments  ;  /, ./'  the  Fallopian  tubes ;  (/,  (/,  the  ovaries. 


lower  end  ;  that  is,  in  the  region  of  the  cervix  or  lower  part  of  the  corpus 
uteri  (Fig.  34).  The  middle  portions  of  Midler's  ducts  have  evidently  begun 
to  fuse  together,  but  coalescence  has  stopped  short  of  the  normal,  and 
an  organ  is  produced  exhibiting  externally  clear  indications  of  its  two- 
horned  origin.  The  bicornate  uterus  is  the  connecting  link  between  the 
uterus  did  dphy.s,  in  which  the  external  appearances  show  two  qui  to  ununited 
lialves,  and  the  uterus  septus  or  bilocularis,  in  which  outwardly  the  organ 
gives  no  indication  of  duplicity.  The  uterus  bicornis  also  shows  all  the 
possible  grades  between  the  variety  in  which  there  are  two  horns  united 
only  in  the  cervical  region,  and  that  in  which  the  double  character  of  the 
organ  is  indicated  merely  by  a  depression  or  notch  at  the  fundus  (uterus 
introrsum  araxatus  or  uterus  cordiformis).  The  two  horns  may  be  prac- 
tically equal  in  size;  but,  on  the  other  hand,  one  may  be  much  less 
develo})ed  than  the  other,  and  in  this  way  there  is  an  approximation  to 
the  type  of  the  uterus  unicornis.     All  the  intermediate  varieties  have 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN    WOMAN     77 


been  observed.  The  degree  of  separation  of  the  horns  varies  greatly. 
In  the  most  marked  cases  they  are  far  apart  superiorly,  and  between 
them  is  frequently  found  a  band  or  frenum  (recto-vesical  ligament) 
passing  from  the  bladder  to  the  rectum.  In  less  evident  cases  the 
horns  lie  close  together,  but  are  not  united ;  and  in  yet  other  instances 
a  shallow  depression  at  the  fundus  shows  that  fusion  of  the  two 
Mlillerian  ducts  has  closely  approached  the  degree  found  in  the  normal 
uterus.  When  the  horns  are  markedly  separate  the  left  one  is  usually 
directed  slightly  forwards,  showing  that  some  degree  of  uterine  torsion 
has  occurred.     In  other  cases  they  may  lie  exactly  side  by  side. 

The  cervix  uteri  may  be  broad  and  large,  and  may  show  a  double  orifice 
(uterus  bicornis  duplex,  septus,  or  bicameratus)  ;  it  may  be  large,  but  with 
only  one  os ;  or  it  may  be  of  normal  size  and  provided  with  a  single 
orifice  (uterus  bicornis  unicollis).  The  vagina  may  be  septate,  subseptate, 
or  single,  and  the  external  genitals  are  usually  normal.  Sometimes 
there  are  anomalies  of  neighbouring  or  more  distant  organs,  for  example 
ectopia  vesicae  said  Polydactyly ;  and  such  monstrosities  as  cyclojna  and 
anencephcdy  have  been  noted  in  non-viable  infants  with  this  type  of 
uterine  anomaly. 

With  regard  to  the  internal  appearances  of  the  uterus  bicornis  it  is 
common  to  find  a  septum  dividing  that  part  of  the  organ  which  appears 
single  externally  into  two  compartments  internally.  In  other  cases  one 
or  both  horns  may  be  solid,  semi-solid,  or  imperforate  at  one  or  more 
places.  In  such  instances  an  accumulation  of  blood  may  occur  at  puberty 
behind  the  imperforation.    The  cervix  may  show  a  double  or  a  single  canal. 

Cliniccd  Features.  —  Apart  from  the  reproductive  functions  the  uterus 
bicornis  has  little  clinical  importance ;  but  it  has  recently  been  noted  that 
chlorotic  girls  are  not  infrequently  the  subjects  of  this  type  of  anomaly, 
and  probably  chlorosis  is  to  be  regarded  as  a  developmental  morbid  state. 
It  has  been  affirmed  also  that  in  early  life  difficulty  may  arise  in  the 
evacuation  of  the  bladder  and  bowel  from  the  concomitant  malfoi-mations. 

The  menstrual  functions  may  be  variously  affected  by  the  presence  of 
a  didelphous  or  bicornate  uterus.  Menstruation  may  occur  every  fort- 
night, every  month,  or  once  in  two  months.  In  the  first  case  the  discharge 
comes  from  both  uterine  cavities  each  month,  but  there  is  no  coincidence 
of  dates,  and  therefore  it  has  a  fourteen  day  interval.  In  the  second  case 
there  is  either  a  simultaneous  discharge  from  both  wombs,  or  else  the 
menstrual  floAV  is  from  one  cavity  the  one  month  and  from  the  other  the 
next.  And  in  the  third  instance,  as  is  shown  by  a  case  reported  by  T.  A. 
Emmet,  there  is  a  bimonthly  flow  from  one  half,  whilst  on  the  other  side 
there  is  an  imperforate  condition  of  the  horn,  vagina,  or  In-men,  which 
])revents  the  appearance  of  a  discharge.  Dysmenorrhea  is  often  met 
with  and  amenoi-rluva  occasionally. 

Sterility  is  sometimes  associated  with  the  bicornate  uterus,  but,  on 
the  other  hand,  the  patient  is  often  fertile.  Pregnancy  may  occur  in  one 
horn,  and  a  menstrual  discharge  take  place  from  the  other;  a  circumstance 
which   possibly  accounts  for  the  continuance  of  menstruation  during 


78 


SYSTEM   OF  GYNECOLOGY 


gestation  which  has  been  occasionally  noted.  Decidual  membranes  may 
also  form  in  the  empty  horn.  Pregnancy  may  also  occur  in  both  horns 
simultaneously,  or  at  different  but  not  far  distant  dates  ;  and  in  the  latter 
case  may  be  found  the  explanation  of  some  of  the  anomalous  instances 
of  superfoetation.  There  is  evidence  to  shoAv  that  gestation  may  happen 
in  each  horn  alternately.  In  rare  cases  a  tAvin  conception  has  taken  place 
in  one  horn. 

The  bicornate  uterus  may  abort ;  or  labour  may  occur  at  the  full 
term,  when  the  empty  horn  may  show  contractions  as  well  as  the  gravid 
one,  and  its  os  also  may  open.  Parturition  may  be  normal ;  there  may 
be  a  malpresentation ;  the  recto-vesical  band  may  cause  delay  in  the 
passage  of  the  foetal  head,  or  there  may  be  low  implantation  of  the 
placenta  and  haemorrhage.  When,  as  sometimes  happens,  the  pregnant 
horn  is  shut  off  by  a  septum,  gestation  becomes  practically  extra-uterine, 
and  has  all  the  dangers  associated  therewith,  such  as  uterine  rupture. 
Even  in  cases  in  which  there  is  not  unilateral  atresia,  rupture  of  the 
uterus,  or  of  the  septum  between  its  horns,  may  occur. 

The  diagnosis  of  the  presence  of  a  bicornate  uterus  is  often  not 
made  till  pregnancy  and  labour  have  taken  place ;  and  sometimes  not 
even  then.  When  menstruation  occurs  every  fortnight,  or  persists 
during  pregnancy,  the  anomaly  may  be  suspected.  The  presence  of  a 
double  vagina,  cervix,  or  os  uteri  suggests  the  existence  of  a  double 
uterine  cavity;  and  a  thorough  bimanual  examination,  conjoined  with 
the  careful  use  of  the  sound,  if  there  be  no  evidence  of  pregnancy, 
ought  to  clear  up  the  case.  The  instances  in  which  one  horn  is 
imperforate  are  rarely  diagnosed. 

Uterus  Septus.  —  Pathology.  —  The  uterus  septus,  or,  as  it  is  also  called, 
bilocularis  or  globularis,  by  its  external  appearance  gives  no  indication  of 

the  fact  that  internally  it  is 
divided,  more  or  less  com- 
pletely, into  two  cavities  by 
an  antero-posterior  vertical 
septum  or  partition  (Fig.  35). 
The  cases  in  which  the  septum 
is  imperfect  have,  however, 
also  been  grouped  together 
under  the  name  uterus  sub- 
septus,  or  semipartitus ;  and, 
according  to  the  extent  of  the 
partition,  certain  subvarieties 
have  been  distinguished. 
Thus,  when  it  is  found  in 
both  body  and  cervix,  leaving, 
however,  the  os  externum 
uteri  single,  we  have  the  ute- 
rus suhseptvs  uniforls.  When 
it  exists  in  the  body,  but  floes  W)i  extend  ])eyond  tlus  os  internum,  there 


Yui.Z!).  —  Uterus  septus.  (Aftor  Gravel  and  Miirtin.)  a, 
Vaf^lna  ;  0,  sinjjie,  lower  part  of  cervix  ;  c,  o,  septum, 
thicker  above,  thinner  below ;  d,  rl,  riffht  and  loft 
uterine  cavities;  e,  e,  two  projections  near  the  os 
Internum  uteri ;  /,  fundus  uteri ;  (/,  (/,  Fallojiian  lubes  ; 
/(,,  h,  round  llfc'aments. 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN   WOMAN     'jc, 


is  produced  the  uterus  subseptus  unicollis.  When  it  is  present  only  in 
part  of  the  body  it  constitutes  the  uterus  subseptus  unicorporeus ;  and 
when  it  is  found  only  near  the  os  externum  it  is  the  uterus  b  if  oris  supra 
simpAex.  From  this  enumeration  of  its  varieties  the  pathological  charac- 
ters of  the  uterus  septus  will  be  evident.  It  may  be  added  that  the 
best-marked  type  has  a  normal  fundus,  two  uterine  cavities  situated 
laterally,  and  existing  both  in  body  and  cervix,  and  not  infrequently 
there  is  also  a  partially  or  completely  septate  vagina.  The  uterus  septus 
shows,  therefore,  a  more  advanced  degree  of  fusion  of  the  Milllerian  ducts 
than  does  the  uterus  bicornis ;  but  still  the  fusion  is  incomplete,  as  is 
shown  by  the  more  or  less  perfect  septum  which  remains. 

Clinical  Features.  —  What  has  been  written  regarding  the  clinical 
manifestations  associated  with  the  uterus  bicornis  may  be  applied  also 
to  the  uterus  septus.  Further,  an  incomplete  septum  may  be  the  cause 
of  a  malpresentation — for  instance,  a  transverse  case  —  or  of  a  low  in- 
sertion of  the  placenta.  The  after-birth  may  even  be  attached  to  the 
septum  itself  —  an  arrangement  certain  to  give  rise  to  dangerous  haemor- 
rhage after  the  birth  of  the  infant.  It  would  seem  that  abortion  is  com- 
mon in  this  uterine  anomaly ;  at  any  rate  Ruge,  by  dividing  the  septum  in 
the  case  of  a  patient  who  had  twice  miscarried,  Avas  rewarded  by  finding 
that  her  next  pregnancy  went  to  the  full  term.  The  diagnosis  of  the 
litems  septus  is  only  likely  to  be  made  during  labour,  when  the  hand, 
introduced  into  the  uterus  to  perform  version  or  to  extract  the  placenta, 
may  detect  the  presence  of  the  partition.  As  with  the  uterus  bicornis 
one  cavity  may  not  communicate  Avith  the  vagina,  and  thus  haemato- 
metra  with  its  train  of  symptoms  may  arise. 

Uterus  Unicornis.  —  Pathologi/.  —  The  uterus  unicornis  is  an  organ  in 
Avhich  one  horn  alone  is  well  developed  (Fig.  36).  There  are  two  varieties : 
that  in  Avhich  the  secondhorn  is  altogether  absent  (litems  unicornis  sine  ullo 
rudimento  cornu  alterius),  and  that  in  Avhich  there  is  a  solid  or  hollow 
rudiment  of  it  (uterus  unicornis 
cum  rudimento  cornu  alterius 
solido  seu  excavato).  In  the 
former  case  there  is  complete,  in 
the  latter  partial  defect  of  one  of 
the  ]\Iiillcrian  ducts.  The  uterus 
unicornis  has  really  no  fundus, 
the  single  horn  inclining  to  one 
side  of  the  middle  line  and 
tapering  to  a  point  at  AAdiich  it 

is  continuous  A\dth  the  Fallopian  Fig.  86.  -  rtoms  unicornis,  posterior  view.    (After  Pole 

tube,  and  Avhere  the  round  liga-  |""^  Martin.  <    «,  Ri-ht  lialf  of  uterus  ;  tlie  left  horn 

!    ■          ..       I      T         rni  "^^  ""'^  ''^'''"  ileveloped  ;  h.  right  Fallopian  tube ;  o, 

ment    is    attached.        llie    ovary  left  Fallopian  tube;   d.  left  ovary;   e,  bladder;/, 

thus  comes  to  lie  at  the  apex         ^''"^"'^ '  ^-  ''^'-'^'^  "'■="■'■■*"  "^•'""ent: 
of  the  bent  cone  formed  by  the  single  horn  and  the  corresponding  tube. 
The  cervix  uteri  is  usually  small  and  the  vagina  narroAV.  absent,  or  sejitate. 
The  single  horn  may  also  be  imperfectly  dcA-eloped,  and  may  be  solid  or 


So  SYSTEM  OF  GYNECOLOGY 

partly  excavated.  Certain  concomitant  malformations  have  been  noted  : 
thus,  the  Fallopian  tube,  round  ligament,  and  broad  ligament  are 
commonly  absent  on  the  side  of  the  missing  horn ;  the  corresponding 
ureter  and  kidney  may  also  be  wanting,  and  the  bladder  may  be  developed 
only  on  one  side.    The  ovaries  may  be  present,  but  are  often  rudimentary. 

In  some  cases,  as  has  been  stated  above,  a  rudiment  of  the  second 
horn  may  be  present ;  it  may  be  solid  or  hollow,  and  in  the  latter  case 
its  cavity  may  or  may  not  communicate  with  that  in  the  first  horn. 
Such  cases  form  the  connecting  links  between  the  typical  uterus  unicor- 
nis and  the  bicornate  organ.  This  rudimentary  horn  may  be  the  seat 
of  a  pregnancy,  or  a  collection  of  menstrual  blood  may  be  found  in 
it.  A  fibroid  tumour  may  be  found  attached  either  to  it  or  to  the  other 
better-formed  horn,  as  in  a  case  noted  by  Mangiagalli. 

Clinical  Features.  —  A  patient  with  a  uterus  unicornis  commonly 
gives  a  history  of  amenorrhoea;  but  sometimes  menstruation  goes  on 
normally,  and  pregnancy  occurs  in  the  single  horn.  When  a  rudimentary 
horn  is  present,  and  when  it  becomes  the  seat  of  a  gestation,  a  very  serious 
state  of  aif airs  is  established ;  in  fact  the  case  becomes  practically  one  of 
extra-uterine  pregnancy,  and  is  accompanied  by  the  same  dangers,  that 
is,  rupture  and  intra-abdominal  heemorrhage.  When  the  rudimentary 
pregnant  horn  has  no  communication  with  the  uterus  unicornis  it  seems 
necessary  to  admit  extra-uterine  migration  either  of  the  ovum  or  of  the 
semen. 

The  presence  of  a  uterus  unicornis,  with  or  without  a  rudimentary 
horn,  commonly  passes  unnoticed  during  life ;  unless  it  be  discovered 
during  the  performance  of  laparotomy.  If  the  condition  be  suspected,  a 
careful  bimanual  examination,  aided  by  the  use  of  the  sound,  will  reveal 
the  presence  of  a  thin,  elongated  uterine  body  bent  to  one  side  with  its 
concavity  outwards.  There  will  also  be  a  small  cervix  and  a  narrow 
vagina.  Pregnancy  in  the  rudimentary  horn  cannot  be  distinguished 
from  an  ectopic  gestation  of  the  tubal  variety,  unless  rupture  occur  and 
the  abdomen  be  opened.  In  a  case  seen  by  myself  it  was  mistaken  for 
a  fibroid  tumour,  a  mistake  which  laparotomy  revealed. 

Uterus  Rudimentarius.  —  Pathology.  —  The  name  uterus  rudimentarius 
is  a  vague  one.  From  one  point  of  view  it  may  with  propriety  be 
applied  to  such  anomalies  as  the  uterus  unicornis  or  bicornis.  Further, 
the  distinction  between  it  and  complete  al)sence  of  the  organ  can  only  be 
made  after  a  careful  autopsy.  At  the  same  time,  it  has  been  customary 
to  restrict  the  application  of  the  term  to  the  cases  in  which,  in  place  of 
the  normal  organ,  one  finds  a  body  of  variable  form  consisting  of  fibrous, 
muscular,  or  fibro-muscular  tissue,  sometimes  solid  and  at  other  times 
showing  a  rudimentary  cavity  (uterus  r ad imeiitarius  solidus,  uteriLS  rudi- 
merdarias  partim  excavatus).  Through  its  partly  excavated  variety  it  is 
closely  related  to  atresia  of  tlie  siugh;  uterus.  In  one  form  of  tlie 
rudimentary  uterus  the  walls  are  so  thin  that  it  has  been  called  mevi- 
hraniform  or  the  uterus  mernbranaceus.  More  commonly,  liowever,  a  small 
solid  mass  of  muscular  tissue  is  found  in  the  middle  line  between  the 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN    WOMAN     8i 


folds  of  the  broad  ligament,  which  seems  in  such  a  case  to  sweep  in  an 
almost  unbroken  band  from  one  side  of  the  pelvis  to  the  other.  The 
tubes,  ovaries,  cervix,  and  vagina  are  usually  absent  or  very  imperfect ; 
but  cases  have  been  reported  in  which  the  annexa  were  normal.  The 
external  genitals  are,  as  a  rule,  well  formed.  The  mammae  are  usually 
small,  and  there  is  often  a  poor  growth  of  hair  on  the  mons  veneris. 

Clinical  Features.  —  Since  clinically  the  rudimentary  uterus  cannot 
be  distinguished  from  absence  of  the  organ,  the  symptomatology  of 
the  two  conditions  will  be  considered  together.  The  recent  literature 
of  both  anomalies  will  be  given  at  the  same  time. 

Uterus  Deficiens  seu  Def actus  Uteri.  —  Pathology.  —  Complete  absence 
of  the  uterus,  its  annexa,  and  (to  some  extent  also)  the  external  genitals, 
is  met  with  commonly  enough  in  the  acardiac  twin  and  in  sympodial 
foetuses ;  but  its  occurrence  in  the  adult  and  otherwise  normal  individ- 
ual is  very  rare.  It  is  necessary  to  make  a  complete  post-mortem  ex- 
amination before  it  can  be  definitely  said  that  no  uterus  existed ;  and 
in  most  of  the  reported  cases  such  evidence  is  not  forthcoming.  Fur- 
ther, in  certain  instances  the  individual  was  evidently  a  male  with  un- 
descended testicles,  not  a  female  without  a  uterus. 

When  the  Fallopian  tubes  as  well  as  the  uterus  are  absent  the 
peritoneum  passes  directly  from  the  bladder  to  the  rectum ;  but  when 
they  are  present  it  forms  a  mesentery  for  each,  although  even  then 
broad  ligaments  in  the  strict  sense  of  the  term  can  scarcely  be  said  to 
exist.  The  round  ligaments  are  generally  to  be  found ;  they  end  in  the 
cellular  tissue  between  the  rectum  and  bladder.  The  ovaries  may  be 
absent,  but  generally  they  are  present,  and  then  they  commonly  contain 
no  ovisacs ;  very  rarely  they  are  normal.  The  tubes  when  present  are 
simply  solid  rods  of  tissue,  with  usually  an  open  ostium  abdominale. 
The  vagina  is  often  wanting  entirely ;  but  sometimes  there  is  a  shal- 
low cul-de-sac  (vestibular  canal)  communicating  with  a  vulva  which  is 
usually  normal.  There  may,  however,  be  an  absence  of  the  vulvar  hair. 
In  rare  cases  the  vagina  has  been  found  Avell  developed.  The  pelvis 
has  a  feminine  breadth ;  but  the  mammae  are  often  poorly  developed. 

Clinical  Features.  —  A  woman  without  a  uterus,  or  with  merely  a 
rudimentary  one,  may  have  all  the  secondary  characters  of  her  sex ;  she 
may  have  a  high-pitched  voice,  rounded  outlines,  and  an  absence  of  hair 
on  the  face.  Sexual  desire  may  or  may  not  be  j^resent  —  a  circumstance 
which  is  probably  determined  by  the  state  of  the  ovaries.  Amenorrhoea 
is  practically  constant;  as,  however,  ovulation  may  occur,  menstrual 
molimina  may  be  met  with,  and  there  may  be  vicarious  ha^norrhages  or 
such  acute  pelvic  pain  as  to  necessitate  an  operation  for  the  removal  of 
the  ovaries.  There  is,  of  course,  sterility  always ;  but  the  patient  may 
be  capable  of  coitus  to  a  certain  extent.  Usually,  however,  eohabitar 
tion  is  attended  by  great  pain.  Eepeated  attempts  on  the  part  of 
the  husband  deepen  the  shallow  vestibular  canal,  converting  it  into  a 
cal-de-sac  of  some  depth;  in  other  cases  dilatation  of  the  urethra  is 
brought  about. 


82  SYSTEM  OF  GYNECOLOGY 

Although  it  is  impossible  clinically  to  distinguish  between  absence 
and  a  rudimentary  state  of  the  uterus,  it  is  always  possible  to  ascertain 
the  existeiice  of  one  or  other  of  these  anomalies.  By  passing  the  index 
finger  into  the  rectum  and  a  sound  into  the  bladder,  whilst  the  abdomi- 
nal wall  is  deeply  depressed  from  above,  one  can  determine  that  there 
is  nothing  like  a  fully  formed  uterus  between  the  rectum  and  the  blad- 
der. A  transverse  band  consisting  of  the  tubes  may  be  palpated,  as 
may  also  the  ovaries  when  they  are  present.  These  physical  characters 
taken  in  conjunction  with  the  symptoms  enable  the  gynaecologist  to 
make  a  diagnosis  sufficiently  exact  to  prevent  his  continuing  a  hopeless 
course  of  treatment  by  ferruginous  tonics  and  the  like  for  the  establish- 
ment of  menstruation. 

Uterus  Foetalis.  —  Pathology.  —  The  anatomical  characters,  which  are 
normal  in  the  uterus  during  intra-uterine  life,  may  persist  and  be  found 
in  the  adult.  They  then  constitute  an  anomaly  —  uterus  foetalis.  The 
cervix  uteri  is  longer  than  the  body,  and  its  walls  are  thick,  whilst  those 
of  the  body  are  thin.  The  cervix  also  is  conical  and  os  externum  nar- 
row. The  Avhole  organ  is  cylindrical  in  form,  and  is  small  in  size,  the 
sound  passing  in  for  a  distance  of  only  an  inch  or  an  inch  and  a  half. 
The  term  infantile  uterus  may  be  used  as  a  synonym  for  foetal  uterus ; 
but  a  shade  of  difference  has  been  recognised  by  some  writers.  In  the 
uterus  foetalis  the  folds  of  the  mucous  membrane  are  found  in  the  body 
of  the  organ,  whilst  in  the  infantile  organ  they  exist  only  in  the  cer- 
vix. The  mucous  membrane  also  is  poorly  developed,  and,  according 
to  Sinety,  contains  no  tubular  glands.  The  vagina  may  be  short  and 
narrow,  or  it  may  be  quite  normal.  The  external  genitals  may  be  imper- 
fect, and  the  ovaries  and  tubes  may  either  be  normal  or  rudimentary. 
Mammary  development  is  usually  little  marked.  It  may  be  added  that 
the  uterus  foetalis  may  be  also  a  uteris  bicornis. 

Clinical  Features.  —  With  the  uterus  foetalis  there  is  commonly 
ainenorrhoea ;  sometimes,  however,  there  is  scanty  and  painful  men- 
struation. Sterility  is  a  constant  symptom,  and  there  may  or  may  not 
be  sexual  appetite.  Chlorosis  has  frequ.ently  been  found  associated 
with  a  foetal  or  infantile  uterus.  The  heart  may  be  small,  and  there 
may  be  a  general  hypoplasia  of  the  whole  vasciilar  system.  The  uter- 
ine anomaly  may  be  diagnosed  by  means  of  bimanual  examination, 
aided  by  rectal  touch  and  the  use  of  the  sound.  The  differential 
diagnosis  between  the  uterus  foetalis  and  the  uterus  pubescens  is  chiefly 
founded  u]jon  the  state  of  the  cervix.  In  the  former  it  is  fairly  firm, 
especially  in  the  supra-vaginal  portion ;  in  the  latter  it  is  thin  and  re- 
laxed. The  condition,  however,  may  be  comjjlicated  and  to  some  ex- 
tent masked  by  concomitant  perimetritis  and  metritis.  Attempts  at 
treatment  of  the  anomaly  have  almost  invariably  ended  in  failure ;  and 
practically  the  only  thing  to  be  done  is  to  relieve  the  dysmenorrhoea,  if 
it  he  y)resent,  by  the  use  of  drugs,  or  possibly,  if  severe,  by  oophorectomy. 

Uterus  Pubescens.  —  Patliolofjij. — The  pubescent  uterus  occu])ies  an 
interiMcdiate  position  Ijetwecn  ilie  uterus  f(jetalis  and  the  normal  virginal 


MALFORMATIONS    OF  THE    GENITAL    ORGANS  IN    WOMAN     83 

organ.  It  shows  a  persistence  of  the  anatomical  characters  which  are 
normal  before  the  epoch  of  puberty.  The  organ  is  small  in  size,  weighs 
less  than  normal,  and  has  a  cervix  and  a  body  of  practically  equal 
length.  The  ovaries,  tubes,  vagina,  and  mammae  may  or  may  not  share 
in  this  condition  of  hypertrophy. 

Clinical  Features.  —  The  symptoms  of  pubescent  uterus  closely  re- 
semble those  associated  with  the  foetal  or  infantile  organ.  JMenstruatioii 
may  be  absent  or  scanty  and  irregular.  Sterility  is  common,  but  there 
is  always  the  hope  that  the  organ  may  yet  undergo  further  development 
and  the  patient  become  pregnant.  Signs  of  general  Aveakness,  chlorosis, 
or  rickets  may  coexist ;  but  the  anomaly  may  also  be  met  with  in  strong 
and  healthy  women.  The  diagnosis  is  made  by  the  same  means  as  in 
cases  of  foetal  uterus,  especial  attention  being  paid  to  the  condition  of 
the  cervix  and  its  size  compared  with  that  of  the  body  of  the  organ.  If 
the  condition  be  discovered  before  marriage,  the  treatment  to  be  adopted 
is  a  general  tonic  one,  consisting  in  the  use  of  gymnastic  exercises,  of 
nourishing  food,  and  of  iron,  quinine,  and  arsenic.  After  marriage  the 
periodical  passing  of  the  sound,  the  insertion  of  an  intra-uterine  stem- 
pessary,  and  electricity  may  all  be  employed  with  some  hope  of  success. 
The  effect  of  marriage  itself  may  be  beneficial ;  emmenagogues  are  of 
doubtful  efficacy.  Marriage  ought  not  to  be  recommended  unless  men- 
struation has  become  established. 

Uterine  Atresia  and  Stenosis.  — Patholog;/.  —  The  uterus  may  be  con- 
genitally  imperforate ;  an  anomaly  which  finds  its  explanation  in  the 
originally  solid  condition  of  the  ducts  of  Muller  from  which  it  is  devel- 
oped. Uterine  atresia  is  not  so  much  an  independent  malformation  as  a 
complica,tion  of  other  anomalies  of  the  organ,  for  instance  of  its  bicornate 
and  unicornate  condition.  Nevertheless  it  occurs  also  in  cases  of  single 
and  otherwise  normal  uteri.  The  whole  cervix  may  be  solid,  or  there 
may  simply  be  a  septum  at  the  os  externum  or  os  internum  uteri.  At 
the  age  of  puberty  menstrual  blood  begins  to  accumulate  behind  the 
obstruction,  leading  in  time  to  the  distension  of  the  uterus  (ha?matometra). 
AVhen  one  horn  of  a  bicornate  uterus  is  imperforate,  unilateral  haemato- 
metra  is  produced;  when  both  horns  are  occluded  there  is  bilateral 
hsematometra.  When  the  obstruction  is  situated  at  the  os  internum, 
only  the  body  of  the  uterus  becomes  distended,  the  cervical  canal 
retaining  its  natural  form.  An  accumulation  of  blood  may  be  found  in 
the  tubes  also  (hteniatosalpinx),  and  it  Avoidd  api)ear  that  the  source  of 
the  blood  is  the  tubal  mucosa,  and  that  it  is  not  due  to  regurgitation 
from  the  uterine  cavity.  When  there  is  simply  narrowing  of  the  cervical 
canal  Avithout  atresia  the  condition  known  as  uterine  stenosis  is  produced. 

Clinical  Features.  —  Since  the  symptoms  of  uterine  atresia  are  iiiainly 
those  of  hsematometra,  and  since  these  are  found  also  in  association 
with  atresia  vaginiB,  their  consideration  will  be  deferred  till  that  vaginal 
anomaly  has  been  described.  In  the  cases  of  uterine  stenosis  dysmenor- 
rhoea  is  the  leading  symptom,  and  dilatation  of  the  cervical  canal  is 
needed  for  its  cure.     Uterino  atresia  requires  puncture  and  subsequent 


84  SYSTEM   OF  GYNALCOLOGY 

dilatation  of  the  obstruction  for  its  relief.  This  should  be  done  with 
strict  antiseptic  precautions ;  and  when  the  accumidated  fluid  has  es- 
caped the  cavity  should  be  packed  with  iodoform  gauze  for  some  days, 
and  douched  occasionally  with  weak  antiseptic  solutions. 

Transverse  Septum  in  the  Cervix  Uteri.  —  Patliolociy.  —  A  condition 
somewhat  similar  to  atresia  uteri  is  the  presence  of  a  valvular  fold  or 
diaphragm  in  the  cervical  canal.  When  the  os  externmn  has  been  di- 
lated the  valve  may  present  the  appearance  of  a  second  cervix  within 
the  first.  It  is  possibly  produced  in  the  same  manner  as  the  more 
common  transverse  septa  of  the  vaginal  canal. 

Clinical  Features.  — The  septum  would  seem  to  act  like  a  polypus, 
and  give  rise  to  haemorrhage  and  pain.  It  has  been  excised  with  com- 
plete relief  of  symptoms.  It  may  also  be  the  cause  of  dystocia ;  but 
this  is  not  a  constant  effect. 

Minor  Malformations  of  the  Uterus.  —  Miiller  of  Berne  has 
recently  pointed  out  the  frequency  of  certain  minor  abnormalities  of 
the  uterine  fundus.  Amongst  these  is  the  anvil-shaped  uterus  (uterus 
incudiformis  or  hiangularis),  in  which  the  normal  convexity  of  the  fun- 
dus is  wanting,  and  a  straight  line  joins  the  two  Fallopian  tubes.  It 
closely  resembles  the  uterus  with  a  flat  fundus  (uterus  ])lardfundalis)  of 
Ftirst's  classification,  and  may  coexist  with  partial  or  complete  duplica- 
tion of  the  uterus  and  vagina. 

The  vaginal  cervix  may  be  rudimentary  or  absent  (uterus  jKvroicollis 
or  acollis),  whilst  the  body  of  the  organ  may  be  normal,  small,  atresic, 
or  membraniform.  A  case  of  this  kind  has  recently  been  reported  by 
Penrose.  Again,  a  f renum  may  be  found  dividing  the  os  externum  into 
two  orifices  {uterus  biforis),  a  condition  which  is  normal  in  the  ant-eater 
(Pozzi).  This  exists  Avithout  any  other  trace  of  duplication  of  the  geni- 
tal canal.  It  may  complicate  labour,  during  which  it  may  be  torn  and 
give  rise  to  haemorrhage.  In  order  to  prevent  this  it  ought  to  be  kept 
to  one  side  or  divided  between  two  ligatures. 

A  condition  which  may  easily  be  mistaken  for  the  uterus  unicornis 
is  that  in  which  there  is  asymmetry  of  the  organ,  one  side  being  better 
developed  than  the  other.  The  uterus  bends  towards  the  better-devel- 
oped side  (latero-version  or  obliquity  of  the  iiterus),  and  the  round  liga- 
ment on  that  side  is  relatively  short.  Latero-position  of  the  uterus  is 
met  with  when  one  of  the  broad  ligaments  is  less  developed  congeni- 
tally,  and  is  to  be  distinguished  from  the  acquired  condition  due  to 
unilateral   iiiflauiiiiatioii   and  cicatricial  contraction. 

Congenital  Prolapsus  Uteri.  —  Patholor/j/.  — What  has  been  called  con- 
genital prolapsus  uteri  is  an  exceedingly  rare  anomaly.  I  have  recently 
met  with  a  well-marked  example  of  it,  in  which  there  was  a  real  dis])lace- 
ment  downwards  of  the  whole  uterus  as  well  as  a  hypertrophic  condition 
of  the  cervix.  In  my  case,  as  well  as  in  those  of  Heil,  Quisling,  Sehaeffer, 
and  Remy,  there  was  also  spina  bifida  in  the  lumbo-sacral  region.  Now 
these  five  instances  are  t\u'  only  on(!S  with  which  I  am  acquainted;  and 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN    WOMAN     85 

the  fact  that  in  them  all  there  was  this  association  of  spina  bifida  and 
prolapsus  uteri,  seems  to  point  to  a  nervous  factor  in  the  etiology  of 
the  latter  condition. 

Abnormal  Communications  of  the  Uterus.  —  The  uterus  nuiy  in  rare 
cases  communicate  with  the  rectum  or  bladder,  or  with  both  viscera  at 
once.  In  an  extraordinary  instance  reported  by  Mr.  Doran  the  right 
side  of  a  bipartite  uterus  opened  on  the  outer  surface  of  the  body.  There 
may  also  be  a  communication  between  the  uterine  cavity  and  that  of 
the  ascending  colon.  Most  of  these  anomalies  must  be  ascribed  to  a 
partial  or  complete  persistence  of  the  embryonic  cloacal  condition.  "When 
combined  with  vaginal  atresia  it  Avould  seem  that  impregnation  has 
occurred  per  rectum  or  per  urethram. 

Malformations  of  the  Yagixa. — Vaginal  malformations  have 
many  characters  in  common  with  uterine  anomalies,  a  circumstance 
which  is  easily  understood  when  it  is  borne  in  mind  that  both  vagina 
and  uterus  are  derived  from  the  Mllllerian  ducts  of  the  embr^-o.  Fur- 
ther, vaginal  and  uterine  abnormalities  often  coexist  in  the  same  case, 
and  in  many  instances  give  rise  to  very  similar  symptoms.  "Whilst, 
however,  it  is  rare  to  meet  with  abnormal  communications  between  the 
uterus  and  neighbouring  organs,  such  communications  are  much  more 
frequent  in  the  case  of  the  vagina. 

Double  "Vagina  ("Vagina  Septa).  —  PatlioJorju. — A  double  vagina  in 
the  exact  sense  of  the  term  can  only  be  said  to  exist  in  certain  double 
terata,  such  as  the  pygopagous  twins  ;  but  it  has  become  customary  to 
apply  the  name  to  the  cases  in  which  the  two  Miillerian  ducts,  which 
normally  fuse  into  one  canal,  have  remained  separate,  a  septum  inter- 
vening between  the  two  passages  in  part  or  in  the  whole  of  their  extent. 

Just  as  the  uterus  didelphys  is  very  rare,  so  two  vaginal  canals,  com- 
pletely separated  and  each  opening  externally  at  a  separate  vulva,  consti- 
tute an  anomaly  of  a  very  uncommon  form.  The  only  reported  case  of 
the  kind  seems  to  have  been  that  of  Katharine  Kaufmann,  seen  by  Sup- 
pinger  in  1876.  This  child,  who  died  at  the  age  of  twentj'-one  months, 
had  two  vulvae  each  opening  into  a  vaginal  canal.  The  pelvis  Avas  broad, 
and  the  true  pelvis  was  divided  into  two  lateral  cavities  by  a  peritoneal 
fold.  Each  half  contained  a  bladder,  a  \inicornate  uterus  with  an  ovary  and 
a  tube,  and  an  intestinum  rectum.  The  vertebral  column  began  to  divide 
at  the  level  of  the  third  lumbar  vertebra,  and  the  two  coccyges  were 
quite  separate.  This  individual  has  been  placed  amongst  the  double  terata. 

IMuch  more  common  are  the  cases  of  "double"  or  septate  vagina,  in 
which  the  vulva  is  single,  although  the  hymen  may  show  two  openings. 
The  two  canals  are  separated  by  a  longitudinal  septum ;  in  the  great 
majority  of  cases  this  vertical  septum  runs  antero-posteriorly,  and  the 
vaginae,  therefore,  are  situated  laterally ;  in  a  very  few  cases  only  does 
it  pass  transversely,  when  of  course  the  vaginal  canals  lie  one  in  front  of 
the  other.  In  the  latter  case  it  must  be  supposed  that  the  two  unfused 
Miillerian  ducts  have  undergone  partial  rotation.    It  is  rare,  however,  to 


S6  SYS  TEA/  OF  GYNAECOLOGY 

iind  tlie  two  canals  exactly  lateral  in  position  and  exactly  equal  in  size ; 
one,  usually  the  left,  commonly  lies  a  little  in  front  of  the  other,  and 
one  is  nearly  always  a  little  smaller  than  the  other.  The  septum  is 
composed  of  muscular  tissue  covered  by  mucous  membrane,  and  has  the 
consistence  of  the  recto-vaginal  septum.  It  varies,  however,  in  thick- 
ness, and  may  even  at  certain  places  show  perforations.  It  may  extend 
the  whole  length  of  the  canals,  or  it  may  be  absent  below  and  present  above 
(vagina  infra  simplex  or  se^ota  supra),  or  present  below  and  absent  above 
(vagina  septa  infra  or  supra  simplex).  In  the  least  marked  form  there 
is  only  a  ridge  on  the  vaginal  wall.  In  the  great  majority  of  cases  the 
uterus  also  is  double,  and  may  be  didelphous,  bicornate,  or  septate,  and 
then  there  is  usually  one  cervical  orifice  in  each  vagina  ;  but  in  a  few 
recorded  cases  the  uterus  Avas  single,  although  the  vagina  was  double, 
when  of  course  only  one  canal  gave  access  to  a  cervix.  Instances  have 
also  been  reported  in  which  the  uterus  was  unicornate,  then  one  of  the 
vaginae,  that  on  the  same  side  as  the  absent  horn,  was  usually  rudimen- 
tary. This  last-named  type,  however,  scarcely  deserves  to  be  termed  a 
double  vagina.  The  vulva  and  the  hymen  may  be  single,  the  vaginal 
septum  stopping  above  the  level  of  the  ostium ;  but  in  some  cases  the 
hymen  shows  two  lateral  orifices  separated  by  a  bridge  of  tissue.  There 
may  be  atresia  of  one  or  both  vaginal  canals,  leading  in  the  adult  to 
unilateral  or  bilateral  haematocolpos. 

Clinical  Features.  — Double  vagina  does  not  usually  give  rise  to  symp- 
toms prior  to  the  occurrence  of  labour  unless  one  of  the  canals  be  im- 
perforate ;  then  at  the  time  of  puberty  blood  may  begin  to  collect 
behind  the  obstruction,  and  give  rise  to  the  troubles  associated  with 
htematocolpos  and  hsematometra.  It  has  been  stated  that  during  preg- 
nancy the  septum  may  be  absorbed,  but  if  it  be  still  present  at  the  time 
of  confinement  it  may  give  rise  to  trouble  by  obstructing  delivery.  It 
may  tear  and  labour  go  on  naturally ;  on  the  other  hand,  the  rupture  of 
it  may  extend  to  the  vagina  and  uterus  also,  and  fatal  consequences  re- 
sult. In  yet  other  instances  the  septum  is  pushed  to  one  side,  and  no 
delay  in  labour  occasioned.  Dyspareunia  has  been  occasionally  reported 
as  an  effect  of  the  septate  vagina.  The  diagnosis  of  the  anomaly  can 
be  easily  made  by  a  vaginal  examination,  save  in  the  cases  in  which  one 
canal  is  imperforate;  then  the  condition  might  easily  be  mistaken  for  a 
cyst  of  the  vaginal  wall.  The  simple  septum  may  be  safely  divided  by 
scissors  during  labour.  When,  however,  there  is  an  accumulation  of 
menstrual  blood  in  one-half  of  the  canal  it  will  be  necessary  to  open 
the  sac  freely,  more  especially  if  the  contents  are  purulent,  and  to  pack 
the  interior  with  iodoform  gauze. 

Unilateral  Vagina.  —  In  the  rare  cases  in  which  only  one  horn  of  the 
uterus  is  developed  (uterus  unicornis)  there  is  generally  a  similar  con- 
dition of  the  vagina.  In  other  words,  the  lower  end  of  one  of  the 
Miillerian  ducts  has  aborted,  and  the  vaginal  canal  which  exists  repre- 
sents one  and  not  both  of  the  embryonic  tubes  from  which  it  is  normally 
developo.d.     This  being  so,  it  is  not  surprising  to  find  that  the  vagina  is 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN  WOMAN     87 

then  narrow,  and  lies  somewhat  to  one  side  of  the  middle  line.  The 
anomaly  is  so  constantly  associated  with  the  unicornate  uterus  that  any 
special  description  of  it  is  rendered  superfluous. 

Vagina  Rudimentaria. — Vagina  rudimentaria,  like  the  term  uterus 
rudimentarius,  is  a  vague  expression.  It  denotes  an  anomaly  which 
has  also  been  described  as  simple  atresia  and  lateral  atresia  vaginae ; 
and  clinically  no  line  of  demarcation  can  be  drawn  between  it  and 
complete  absence  of  the  vagina  (defectus  vaginae).  It  will  therefore  be 
discussed  under  those  heads. 

Defectus  Vaginae.  —  Patholocjii.  —  Complete  absence  of  the  vagina  is  a 
very  rare  condition  —  one  whicli  is  met  with  chiefly  in  the  allantoido- 
angiopagous  twin  foetus  and  in  the  sireniform  monstrosity.  In  it  no 
muscular  bands  are  found  between  the  bladder  and  rectum,  otherwise 
the  condition  falls  into  the  category  of  vaginal  atresia  or  rudimentary 
vagina.  Probably  it  is  always  associated  with  absence  of  the  uterus, 
Fallopian  tubes,  and  external  genitals,  and  with  an  imperfect  develop- 
ment of  the  mammary  glands. 

Clinical  Features.  —  Since  this  is  a  pathological,  not  a  clinical  morbid 
entity,  the  consideration  of  its  symptoms  will  be  taken  with  those  of 
vaginal  atresia,  a  condition  from  which  it  is  undistinguishable  during 
the  life  of  the  individual. 

Atresia  Vaginae. — Pathology. — Vaginal  atresia  or  imperf oration  is  of 
different  degrees.  In  its  most  marked  form  no  trace  of  the  canal  is  found 
save  a  fibrous  or  fibro-muscular  band  in  the  tissue  between  the  bladder 
and  rectum ;  in  a  less  extreme  form  part  of  tli6  vagina  is  present 
whilst  the  remainder  is  solidly  imperforate ;  and  in  a  still  less  marked 
form  there  is  simply  a  membranous  obstruction  or  perforated  diaphragm 
at  one  part  of  the  passage.  Again,  the  position  of  the  imperf  oration 
varies ;  it  may  exist  throughout  the  whole  length  of  the  canal,  or  it 
may  be  present  only  at  the  upper  part,  the  lower  part,  or  the  middle 
part.  When  the  upper  two-thirds  of  the  vagina  are  occluded  it  has  been 
supposed  that  the  open  lower  third  is  not  truly  vaginal  in  nature,  but 
is  the  enlarged  vestibular  canal,  the  representative  of  the  anterior  part 
of  the  sinus  urogenitalis  of  intra-uterine  life.  Through  the  failure  of  the 
downward  progress  of  the  Mlillerian  ducts  the  vestibular  canal  has  re- 
tained its  early  dimensions ;  its  depth  also  has  probably  been  increased 
by  attempts  at  coitus.  When  only  the  middle  part  of  the  vagina  is 
obstructed  it  may  be  surmised  that  the  upper  canal  is  jNIiillerian.  or  truly 
vaginal  in  character,  whilst  the  lower  portion  is  vestibular.  With  regard 
to  the  condition  of  the  other  genital  organs  in  cases  of  vaginal  atresia 
great  dilferences  exist.  The  uterus  may  be  normal,  rudimentary,  or 
absent.  The  vulva  also  may  be  wanting  or  imperfect,  but  more  usually 
it  is  normn.l  and  the  hymen  is  present.  The  ovaries  are  commonly 
present.  The  urethral  canal  may  be  dilated,  the  result  of  attempts 
at  coitus.  Certain  pathological  changes  commonly  occur  at  ]iuberty : 
if  the  uterus  be  present  and  the  whole  vagina  imperf(n-ate,  hauuato- 
metra  is  developed    and   the   \iterus    converted   into  a  large   rounded 


88  SYSTEM  OF  GYNECOLOGY 

sac  containing  blood,  first  the  cervix  and  later  the  body  becom- 
ing distended ;  if  the  upper  part  of  the  vagina  be  patent,  then  blood 
first  accumulates  in  it,  and  haematocolpos  is  produced,  whilst  haemato- 
metra  is  a  later  development;  and  if  the  vaginal  obstruction  affect 
only  the  lowest  part  of  the  canal,  hasmatocolpos  may  be  the  sole 
result,  the  uterus  remaining  as  a  small  body  surmounting  the  dis- 
tended vaginal  tumour.  Hypertrophy  of  the  vaginal  walls  may  be 
produced,  or  from  the  accuinulation  of  blood  rupture  may  occur  into 
one  or  other  of  the  neighbouring  viscera.  In  certain  instances  the  Fal- 
lopian tubes  also  become  distended  and  hsematosalpinx  results.  The 
contents  of  the  distended  vagina,  uterus,  or  tube  are  usually  treacly  in 
character,  consisting  as  they  do  of  concentrated  blood.  After  rupture 
or  artificial  evacuation  suppuration  may  supervene  in  the  sac,  and 
pyocolpos,  pyometra,  and  pyosalpinx  be  produced. 

Clinical  Features.  —  The  symptoms  associated  with  vaginal  atresia 
are  chiefly  those  due  to  the  accumulation  of  blood  in  some  part  of  the 
genital  canal  at  and  after  the  period  of  puberty.  In  early  life,  it  is  true, 
some  discomfort  may  be  caused  by  the  retention  of  mucus  in  the  patent 
part  of  the  canal,  leading  to  constipation  and  dysuria  by  pressure ;  but 
the  special  clinical  features  are  all  developed  after  puberty.  There  is,  of 
course,  amenorrhoea ;  then  gradually,  unless  indeed  the  uterus  be  absent, 
a  swelling  is  developed  in  the  lower  abdominal  region  in  which  fluctua- 
tion can  often  be  detected.  There  is  sometimes  a  bulging  in  the  region  of 
the  vulva  and  perineum.  These  signs  are  caused  by  the  gradual  accumu- 
lation of  menstrual  blood  behind  the  obstruction.  Severe  pelvic  pain  is 
experienced,  recurring  with  increasing  severity  at  intervals  of  a  month ; 
this  is  sometimes  accompanied  by  vicarious  menstrual  haemorrhages  from 
other  parts  of  the  body,  for  example,  haemoptysis,  or  hsematemesis.  If  the 
patient  marry,  cohabitation  is  found  to  be  very  difficult  and  painful,  if 
not  impossible.  In  time,  however,  the  vestibular  canal  or  urethra 
becomes  distended,  and  an  imperfect  degree  of  connection  is  rendered 
possible ;  then  the  urethral  dilatation  leads  to  dysuria.  There  is  of 
necessity  sterility.  In  a  case  recently  reported  by  Grandin  the  anomaly 
existed  in  several  members  of  the  same  family. 

The  diagnosis  of  the  anomaly  ought  not  to  be  a  matter  of  difficulty. 
When,  in  a  patient  with  amenorrhcea  and  monthly  pelvic  pain  of  in- 
creasing severity,  an  abdominal  tumour,  which  fluctuates  and  gradually 
enlarges,  is  discovered,  the  presence  of  vaginal  atresia  may  be  suspected ; 
and  when,  in  addition,  it  is  found  on  examination  that  the  vagina  is 
blocked  either  near  its  orifice  or  at  its  upper  part,  the  diagnosis  may  be 
safely  made.  Further  examination  by  means  of  rectal  touch,  aided  by 
the  presence  of  a  sound  in  the  V)ladder,  abdominal  palpation,  and  vaginal 
touch  (when  the  lower  part  of  the  vagina  is  patent),  is  chiefly  under- 
taken with  a  view  to  finding  out  the  extent  of  the  atresia  and  the  con- 
dition of  the  uterus  and  ovaries,  so  that  proper  treatment  may  be 
adopted.  In  carrying  out  this  investigation  it  will  be  well  to  give 
the  patient  chloroform.     The  line  of  treatment  will  ha  largely  decided  by 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN    WOMAN     89 

the  extent  and  position  of  the  atresia,  by  the  state  of  the  internal  genital 
organs,  by  the  presence  or  absence  of  retained  blood,  and  by  the  circum- 
stances of  the  patient.  In  the  cases  in  which  there  is  well-marked  vaginal 
atresia  with  absence  of  the  uterus,  but  with  the  presence  of  functionally 
active  ovaries,  as  shown  by  recurring  severe  pelvic  pain,  the  operation  of 
oophorectomy  has  been  recommended  and  successfully  carj-ied  out 
in  several  instances.  When,  on  the  other  hand,  there  is  a  more  or 
less  normal  uterus,  associated  with  hsematocolpos,  entirely  different 
operative  interference  is  indicated.  It  is  not  wise  to  leave  the  blood- 
accumulation  to  nature ;  for  rupture  of  the  sac,  even  when  it  occurs 
through  the  vagina,  is  seldom  safe  in  its  immediate  or  satisfactory  in  its 
ultimate  results.  An  incision  ought  to  be  made  into  the  sac  and  the  con- 
tents evacuated  under  strict  antiseptic  precautions.  If  the  atresia  be 
slight,  and  situated  low  down  in  the  canal,  the  evacuation  may  be  easily 
and  safely  carried  out ;  but  if  a  large  part  of  the  vagina  be  atresic,  diffi- 
culties and  dangers  are  met  with.  Dissection  must  be  carefully  per- 
formed with  a  sound  in  the  bladder  and  a  finger  in  the  rectum  as  guides ; 
and  the  handle  of  the  knife  should  be  freely  iised  in  order  to  avoid  wound- 
ing neighbouring  organs.  When  the  dissection  has  nearly  reached  the 
blood-sac,  as  determined  by  rectal  touch,  a  trocar  should  be  introduced 
to  evacuate  the  fluid,  and  then  the  cavity  should  be  laid  freely  open, 
washed  out  with  antiseptic  lotion,  and  plugged  with  iodoform  gauze. 
If  it  be  found  that  the  accumulation  of  blood  is  in  the  interior  of  the 
uterus,  then  the  same  method  of  procedure  must  be  followed,  with 
even  closer  attention  to  antisepsis.  Puncture  through  the  bladder  or 
rectum  is  not  an  operation  to  be  recommended. 

When  in  a  married  woman  there  is  vaginal  atresia,  but  no  hasmato- 
colpos  or  hsematometra,  operative  interference  need  not  be  urged  unless 
the  patient  herself  anxiously  desires  it.  Then  the  question  of  the  advis- 
ability of  trying  to  create  an  artificial  vagina  will  arise.  It  has  been 
suggested  that  the  uretha  should  be  dilated  to  allow  of  coitus ;  but  the 
proposal  has  not  been  received  with  favour,  and  it  Avould  have  been  sur- 
prising if  it  had.  The  creation  of  an  artificial  vagina  between  the 
bladder  and  rectum  is  a  difficult  operation,  requiring  a  great  deal  of 
careful  dissection ;  and  it  is  followed  in  many  cases  by  disappointing 
results.  If  it  be  attempted,  an  H-shaped  incision  should  be  made  in  the 
vulvar  region,  and  then,  by  means  of  the  finger  rather  than  the  knife,  a 
cavity  of  sufficient  depth  should  be  formed ;  this  cavity  must  next  be 
lined  by  mucous  membrane  and  skin  taken  from  neighbouring  parts  and 
suturecl  into  position ;  it  must  then  be  stuffed  with  iodoform  gauze,  and 
kept  open  afterwards  by  a  wooden  cone-shaped  pessary.  At  a  later 
period  the  canal  is  kept  open  by  coitus.  A  slower  method  of  forming 
the  vagina  is  by  means  of  electrolysis,  and  Le  Fort  has  reported  a  suc- 
cessful case  treated  in  this  manner.  Of  course  it  must  be  borne  in  mind, 
that  as  the  uterus  is  either  absent  or  rudimentary,  which  is  deiuonstrated 
by  the  absence  of  a  blood  accumulation,  the  operation  is  undertaken  solely 
to  allow  the  patient  to  perform  her  part  in  the  act  of  coitus.     This  being 


go  SYSTEM   OF  GYNECOLOGY 

the  case,  it  is  no  matter  for  wonder  that  certain  gynaecologists  have  not 
favonred  any  operative  interference  in  such  cases. 

Atresia  Vaginae  Lateralis.  —  Pathology.  —  It  has  been  already  noted 
under  the  head  of  Septate  Vagina  that  one  of  the  canals  may  be  imper- 
forate at  its  vulvar  end,  whilst  one  of  the  uterine  orifices  opens  into  it 
above.  In  this  way  a  lateral  vaginal  pouch  or  sac  is  formed,  atresia 
vagince.  lateralis.  Menstrual  blood  may  collect  in  the  sac  and  distend  it, 
giving  rise  to  the  condition  known  as  lateral  haematocolpos ;  suppuration 
may  also  occur  in  it  —  lateral  pyocolpos.  The  half  uterus  Avith  which 
it  communicates  may  likewise  be  distended  with  blood  or  pus  (lateral 
hcematometra  or  pyometra).  This  vaginal  anomaly  is  nearly  always  situ- 
ated on  the  right  side  (Puech). 

Clinical  Features.  —  As  in  other  vaginal  anomalies,  symptoms  do  not 
arise  till  after  puberty,  when  the  gradual  dilatation  of  the  lateral  vaginal 
sac  gives  rise  to  dysmenorrhoea,  pain  in  the  back,  dysuria,  and  pain  on 
defeecation.  Vaginal  examination  reveals  an  elastic  tumour  on  one  side, 
which  may  be  confounded  Avith  pelvic  haematocele  ;  but  may  usually  be 
distinguished  by  its  position  and  gradual  increase  in  size.  Rupture 
may  spontaneously  occur,  either  of  the  vaginal  or  uterine  septum,  and 
dark  syrupy  blood  or  pus  be  discharged.  This  is  usually  followed  by  re- 
accumulation  in  the  sac,  by  an  increase  in  the  severity  of  the  symptoms 
and  possibly  the  supervention  of  pelvic  peritonitis  and  even  of  death. 
The  treatment,  therefore,  ought  to  be  free  incision,  washing  out  of  the  sac 
with  an  antiseptic  solution,  and  in  many  cases  excision  of  the  sac  wall. 

Winckel  has  pointed  out  that  inversions  or  prolongations  of  the 
vaginal  mucous  membrane  may  be  met  with,  and  may  extend  into  the 
muscular  layers  of  the  wall  and  even  into  the  paravaginal  cellular  tissue. 
These  pockets  have  thin,  smooth  walls,  may  be  from  1  to  1^  inch  in 
length,  and  must  not  be  confounded  with  lateral  vaginal  atresia. 

Stenosis  Vaginae.  —  Pathology.  —  The  vaginal  canal  may  be  abnormally 
or  unusually  narrow.  The  association  of  this  anomaly  with  the  uterus 
unicornis,  and  with  atresia  vaginae  lateralis,  has  been  referred  to ;  but  it 
may  also  occur  in  connection  with  the  uterus  fostalis,  or  even  with  a 
normal  organ.  The  stenosis  may  affect  the  whole  vaginal  canal,  or  may 
be  present  at  certain  points  only.  In  the  latter  case  it  is  probably  due 
to  adhesive  colpitis  occurring  in  foetal  life  or  in  the  young  infant.  The 
narrowing  may  be  circular,  diagonal,  or  in  spiral  ridges.  The  so-called 
supplementary  hymen  is  probably  of  this  nature.  The  condition  is 
closely  allied  to  if  not  identical  with  transverse  complete  or  perforated 
diaphi-agms  in  the  vagina. 

CJlin/ical  Featii/res. — If  the  stenosis  l)c  slight  it  may  give  rise  to  no 
inconvenience ;  for  coitus,  or  labour  if  coitus  fail,  usually  serves  to  dilate 
the  canal  completely.  In  more  severe  cases  it  may  be  necessary  to  resort 
to  artificial  dilatation,  incision,  or  even  excision  of  the  constricting  bands. 
H,'jr;matocolpos  is  seldom,  if  ever,  a  result  of  vaginal  stenosis  if  the  dia- 
phragm be  complete.  Rupture  of  the  canal  may,  however,  occur  in 
labour  imless  the  obstruction  is  incised. 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN   WOMAN     91 

Abnormal  Communications  of  the  Vagina.  —  The  vagina  may 
open  into  the  rectum  through  an  imperfect  development  of  the  recto- 
vaginal septum,  which  normally  intervenes  between  the  two  canals. 
Further,  the  canal  may  communicate  by  a  small  orifice  with  the 
urethra.  Most  of  the  cases  of  abnormal  communication  of  the  vagina 
with  the  rectum,  urethra,  and  bladder  are  not  really  vaginal,  but  vulvar 
anomalies ;  being  true  instances  of  persistence  of  the  cloaca  of  embry- 
onic life,  or  of  the  sinus  urogenitalis.  They  Avill  be  described  amongst 
the  malformations  of  the  vulva.  Very  rarely,  however,  cases  of  con- 
genital ano-vaginal  and  vagino-urethral  fistula  have  been  described.  In 
these  instances  the  anus  and  rectum  and  the  urethra  are  normally  formed, 
and  the  Miillerian  vagina  is  present  at  the  level  of  the  fistulous  communi- 
cations. In  these  cases  the  vagina  ]nay  be  septate.  Caradec  reported  an 
example  of  this  anomaly  in  which  there  was  a  communication  between 
the  rectum  and  vagina,  the  anus  and  rectum  being  normal ;  and  Fordyce 
recently  described  a  new-born  infant  with  foetal  peritonitis,  in  which  each 
of  the  two  halves  of  a  double  vagina  opened  by  a  small  aperture  into  the 
urethra.     In  the  latter  case  both  vaginal  canals  were  atresic  inferiorly. 

Malformations  of  the  Vulva.  —  In  considering  the  malformations 
of  the  ovaries,  tubes,  uterus,  and  vagina,  it  has  been  found  most  con- 
venient to  discuss  first  the  anomalies  of  these  organs  separately,  and  then 
to  refer  to  those  combinations  of  the  anomalies  which  are  most  commonly 
met  with.  Thus  unilateral  absence  of  the  Fallopian  tube  was  first  de- 
scribed separately,  and  it  was  pointed  out  later  that  it  was  usually 
associated  with  a  uterus  unicornis  and  a  unilateral  vagina.  In  dealing 
with  the  malformations  of  the  vulva,  however,  this  plan  is  not  so  useful, 
for  now  we  have  to  do  rather  with  groups  of  anomalies  than  with  single 
ones.  Thus,  whilst  something  must  be  said  regarding  abnormalities  of 
the  clitoris,  labia,  and  hymen,  our  main  attention  Avill  be  turned  to  such 
associations  of  defects  as  are  found  in  the  cloacal  conditions,  and  in  the 
cases  of  so-called  hermaphroditism. 

Double  Vulva. — The  anomaly  to  which  the  name  double  vulva  may 
be  correctly  applied  is  a  very  rare  one.  In  the  case  of  Katharine  Kauf- 
mann,  already  referred  to  under  the  head  of  "^  double  vagina,"  there  were 
two  well-marked  vulvae  separated  by  a  raphe.  There  were  on  each  side 
two  labia  majora  and  minora,  a  clitoris,  hymen,  urethra,  and  anus.  IVfore 
recently  Chiarleoni  has  reported  a  less  Avell-marked  case  in  a  living  infant, 
thirty-three  months  old.  In  this  child  there  were  also  two  vulvar  aper- 
tures, of  which  the  left  lay  somewhat  obliquely ;  but  the  anus  was 
imperforate,  and  the  condition  of  the  internal  organs  was  not  ascer- 
tained. The  cases  of  Blanche  Dumas  and  of  Mrs.  B.  (reported  by  "Wells) 
might  be  cited  as  examples  of  double  vulva;  but  in  them  there  were 
supernumerary  lower  limbs. 

Def actus  Vulvae.  —  Complete  absence  of  the  vulva  (defect ks  or  atresia 
vulvae)  is  an  anomaly  met  with  only  in  non-viable  fa^tuses.  chiefly  of  the 
acephalic  and  sympodial  types.    The  skin  passes  Avithout  any  irregularity 


92 


SYSTEM   OF  GYNECOLOGY 


or  solution  of  contimiity  from  the  symphysis  pubis  to  the  coccyx.  In 
such  a  case  the  anus  is  absent ;  but  this  is  not  constant,  for  in  some 
instances  an  anal  orifice  has  been  found.  Internally  the  rectuni,  bladder, 
and  genital  ducts  may  all  open  into  one  cavity  — persistence  of  the  cloaca; 
in  other  cases  the  recto-vaginal  septum  has  developed,  but  the  bladder 
and  genital  ducts  have  a  common  termination  — persistence  of  the  sinus 
'urogenital is.  During  foetal  life  an  accumulation  of  urine  in  the  bladder 
and  genital  canals  takes  place,  and  the  infant  shows  at  the  time  of  birth 
considerable  abdominal  distension  from  this  cause.     Cases  of  so-called 


■"^^«Si 


Fio.  87.  —  Atresia  viilvu'  Miiicrliciulis.     (After  Kimsclinini:?.) 


absence  of  the  vulva  in  the  adult  woman  are  probably  instances  of  the 
anomaly  next  to  be  described,  atresia  vnlcai  superficialis.  Defectus  vulvae 
in  the  sti-i(;t  sense  oF  the  toi'iii  lias  no  clinical  importance. 

Atresia  Vulvae  Superficialis.  —  J'afholof/!/. — Tlie  term  supcrlicdal  vulvar 
atresia  may  Iji;  aj)plied  to  tliose  cases  in  which,  on  account  of  adhesion 
of  tlie  labia  majora  or  minora,  there  is  an  apparent  absence  of  the  vulvar 
cleft  (Fig.  37).  Usually  Hk;  occlusion  is  not  complete,  for  a  small  orifice  is 
commonly  found  near  the  root  of  the  clitoris  through  which  the  menstrual 
fluid  and  urine  escape.    The  anomaly  may  be  present  ;tt  birth,  or  may  be 


MALFORMATIONS    OF   THE    GENITAL    ORGANS  IN    IV  DM  AN     93 

developed  in  infancy.  In  both  cases  it  is  doubtless  due  to  adhesive 
vulvitis  which  leads  to  a  glueing  together  of  the  labia. 

Clinical  Features.  —  In  early  life  there  may  be  difficulty  in  micturi- 
tion. After  puberty  the  escape  of  the  menstrual  flow  may  be  impeded, 
but  haematocolpos  does  not  usually  result.  After  marriage  the  labial 
adhesion  will  prevent  coitus,  but  not  necessarily  impregnation.  It  is 
possible  on  a  superficial  examination  that  the  condition  may  be  mis- 
taken for  atresia  vulvae.  It  is  usually  easy  to  separate  the  labia  by 
traction ;  but  if  this  fail,  a  sound  should  be  passed  in  through  the  an- 
terior opening  and  a  careful  dissection  made  down  to  it.  Attempts  at 
coitus  may  be  sufficient  to  break  down  the  adhesion. 

Vulva  Infantilis.  —  In  the  adult  the  vulva  may  have  preserved  its 
infantile  type  and  characters.  This  anomaly  is  usually  associated  with 
defective  development  of  the  uterus  and  ovaries,  and  with  such  sys- 
temic disorders  as  chlorosis.  Its  clinical  importance  is  small  compared 
with  that  of  the  associated  defects ;  but  the  existence  of  an  infantile 
vulva  may  have  some  value  as  an  indication  of  imperfect  development 
of  the  internal  genital  organs. 

Abnormal  Commuxications  of  the  Vulva.  —  It  will  be  remem- 
bered that  during  development  there  is  a  time  Avhen  the  allantois 
(bladder),  Mlillerian  ducts  (vagina),  and  rectum  all  open  into  a  common 
cavity,  which  in  its  turn  opens  on  the  surface  of  the  body,  and  is  called 
the  cloaca.  Normally  this  condition  is  transitory;  but  in  certain  cases 
it  is  permanent,  and  thus  the  anomaly  known  as  atresia  ani  vaginalis 
or  vulvar  anus  is  produced.  In  other  cases  development  has  advanced 
a  stage  further  before  it  is  arrested ;  the  perineal  partition  has  grown 
downwards  and  separated  the  rectum,  which  now  opens  externally  at  the 
anus,  from  the  rest  of  the  cloacal  cavity,  which  is  now  known  as  the  uro- 
genital sinus.  The  persistence  of  the  urogenital  sinus,  into  which  bladder 
and  genital  ducts  open,  gives  rise  to  the  anomaly  known  as  hypospadias 
in  the  Avoman.  Female  epispadias,  a  somewhat  puzzling  and  very  rare 
malformation,  may  also  be  described  here. 

Atresia  Ani  Vaginalis  (Anus  Vulvalis).  —  Patliologij.  —  The  term  ''per- 
sistent cloaca  "  ought,  perhaps,  to  be  given  to  this  anomaly  rather  than 
the  cumbersome  and  not  strictly  accurate  expression  "atresia  ani 
vaginalis."  "■Anus  vidvalis,'"  "anus  vagincdis,^^  and  "anus  vidvo  vagi- 
nalis/' are  also  names  which  have  been  applied  to  this  malformation. 
Apparently  the  normal  anus  is  absent,  and  the  rectum  opens  into  the 
vagina  or  the  vulva  (Fig.  38).  Strictly,  however,  by  imperfect  down- 
growth  of  the  perineal  partition,  the  rectum  opens  not  into  the  vagina 
or  vulva,  but  into  the  urogenital  sinus.  The  ]\Iiillerian  ducts  have  not 
yet  grown  downwards  to  form  the  lower  part  of  the  vagina.  "What  is 
commonly  regarded  as  vagina  is,  therefore,  not  truly  so,  but  is  the  canal 
or  sinus  which  precedes  the  development  of  the  vagina.  In  the  com- 
munication of  the  rectum  with  this  sinus  there  is,  therefore,  a  persist- 
ence of  the  cloacal  stage. 


94 


SYSTEM   OF   GYNyECOLOGY 


Clinical  Features.  —  The  cliief  symptom  of  this  anomaly  is  the  pas- 
sage of  the  fasces  through  an  opening  either  in  the  neighbourhood  of 
the  vestibule  or  in  that  of  the  posterior  commissure.  In  some  instances, 
when  there  is  a  sphincter,  the  patient  has  control  over  the  f^ces  ;  but  in 
other  cases  there  is  no  such  control.  In  the  latter  case  the  external 
genitals,  which  are  kept  constantly  moist,  are  apt  to  be  sore.  So  uncom- 
fortable is  the  patient  thus  rendered,  that  she  gets  into  the  habit  of 
inducing  constipation  to  render  the  emptying  the  bowels  a  weekly  instead 
of  a  daily  act.  When  there  is  control  over  defaecation  there  is  not  any 
pressing  need  for  operative  interference;  but  the  sinus  urogenitalis 
ought  to  be  douched  after  each  motion.  When,  on  the  other  hand,  there 
is  fsecal  incontinence  it  will  be  necessary  to  operate,  and  the  age  when 


Fig.  38.  — Anus  vulvalis.     (After  Dwight.) 


interference  is  most  likely  to  be  successful  is  that  of  fifteen  years  or  later, 
when  the  fseces  are  fully  formed  and  the  tissues  can  be  more  easily 
moulded.  The  usual  operation  consists  in  the  passage  of  a  probe  through 
the  fistula,  and  the  bringing  of  it  out  in  the  position  where  the  anal 
aperture  ought  to  be.  The  parts  between  the  probe  and  the  skin 
surface  are  then  to  be  divided,  and  the  rectum  pulled  down  and  sutured 
into  position.  As,  however,  by  this  means  a  permanent  cure  can  very 
rarely  be  obtained,  Buckmaster  lias  recently  advocated  a  modification 
of  the  operation.  ][e  advises  that  the  j)robe  should  be  brought  out, 
not  in  the  position  where  the  anus  should  bo,  but  in  front  of  it,  just 
above  the  levator  ani  muscle.  Then  the  tissues  above  the  probe  are  to 
be  divided,  and  the  rectum  drawn  to  tlie  skin  and  fastened  there,  but 
without  strain.     'J'he  raw  surfaces  inust  then  be  sowed  together.     At  a 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN   WOMAN     95 

later  period  the  fibres  of  the  levator  aui  are  to  be  split,  as  are  those  of 
the  rectus  muscle  in  gastrostomy,  in  order  to  get  a  good  sphincter.  It 
remains  to  be  seen  whether  this  method  of  operation  will  3'ield  more 
satisfactory  results  than  the  older  one. 

Persistent  Urogenital  Sinus  (Hypospadias  in  Woman) .  —  Patltolorjy. 
—  In  one  sense  it  is  incorrect  to  speak  of  hypospadias  in  the  woman 
as  an  anomaly,  for  the  normal  woman,  as  regards  her  external  genitals, 
may  be  called  a  hypospadiac  man.  There  is,  however,  a  malfor- 
mation of  the  female  genitals  to  which  this  name  has  been  commonly 
given.  Properly  speaking,  it  is  a  persistence  of  the  urogenital  sinus ; 
the  urethra  appears  to  open  into  the  vagina ;  but  what  is  regarded  as 
vagina  is  really  sinus  urogenitalis.  Through  a  common  opening  at  the 
base  of  the  clitoris,  which,  it  may  be  remarked,  often  shows  hypertrophy, 
both  the  urine  and  the  menstrual  fluid  escape.  The  perineum  is  normally 
formed,  and  the  rectum  opens  separately  behind  it  at  the  anus.  Thus 
the  condition  differs  from  the  persistent  cloaca  of  atresia  ani  vaginalis. 
Pozzi  describes  two  varieties,  differing  in  degree,  of  hypospadias  in  the 
female  subject.  In  one,  which  represents  the  minor  degree,  the  vestibular 
canal  is  long  and  narrow,  and  receives  the  opening  of  the  urethra  and 
vagina  fairly  high  up.  Very  frequently  this  type  is  accompanied  by  a 
hypertrophy  of  the  clitoris,  and  thus  a  condition  of  parts  is  produced 
which  may  give  rise  to  some  doubt  as  to  the  sex  of  the  individual.  In 
the  second  degree,  which  may  be  called  hypospadia  proper,  the  uro- 
genital canal  has  disappeared ;  but  the  lower  part  of  the  allantois,  which 
ought  to  have  been  changed  into  the  urethral  canal,  has  been  included  in 
the  formation  of  the  bladder.  There  is  thus  absence  of  the  urethra,  and 
the  vagina  and  bladder  open  together  into  the  vestibular  canal ;  so  that 
it  appears  as  if  the  bladder  opened  directly  into  the  vagina.  Cases  of 
this  kind  have  recently  been  reported  by  Strong  and  Prank.  There  will 
be  incontinence  of  urine  as  a  symptom. 

Epispadias  in  Woman.  —  Pathology.  —  Epispadias,  as  a  defect  of  the 
upper  wall  of  the  urethra  is  called,  may  occur  alone,  or  it  may  be 
associated  with  malformations  of  the  bladder  and  anterior  abdominal 
wall.  In  the  former  case  the  urethra  is  seen  as  an  open  groove 
passing  iipwards  in  the  position  of  the  vestibule,  and  disappearing 
under  the  symphysis  pubis,  to  end  directly  either  in  the  bladder,  or  in 
the  upper  and  closed  part  of  the  urethra ;  for  the  defect  may  be 
present  only  in  part  of  the  canal.  On  each  side  of  it  lies  one-half 
of  the  split  clitoris,  and  attached  to  each  half  is  the  upper  end  of  one 
labium  minus.  The  labia  majora  may  unite  normally  in  front  or  may 
diverge.  The  bladder  is  closed  in  anteriorly,  and  there  is  usually  no 
separation  of  the  symphysis  pubis  ;  it  is,  however,  broader  than  normal. 
The  growth  of  hair  in  the  median  line  of  the  mons  veneris  may  be  defec- 
tive, as  in  a  case  of  female  epispadias  seen  by  myself.  The  bladder 
cavity  is  commonly  diminished  in  size.  In  the  other  forni  of  epispadias 
the  anomaly  is  complicatod  by  ectopia  vesicae  (extroversion  of  the  bladder) 
and  by  a  failure  of  union  of  the  arcus  ossium  pubis.     In  this  case  the 


96  SYSTEM  OF  GYN.-ECOLOGY 

upper  ends  of  the  labia  majora  are  wide  apart,  and  the  urine  escapes 
directly  from  the  ureters.  Sometimes  it  is  not  the  bladder  which  is  thus 
open  to  the  fl'ont,  but  the  cloaca  —  development  not  having  proceeded  so 
far  as  to  form  a  separate  bladder.  Intermediate  types  may  be  found 
between  those  two  varieties,  the  simple  and  the  complicated ;  and  these 
serve  as  connecting  links.  It  is  with  the  first  variety,  however,  that 
we  have  here  specially  to  do.  Epispadias  is  much  rarer  in  the  female 
than  the  male  subject  —  a  circumstance  which  has  not  yet  found  a 
satisfactory  explanation.  Whether  the  anomaly  be  due  to  the  rupture  of 
parts  already  fused  together,  or  to  the  failure  of  union  of  structures  which 
normally  grow  together,  has  not  yet  been  definitely  settled.  •  Durand 
seems  to  connect  it  Avith  an  imperfect  formation  of  what  Tourneux  terms 
the  "bouchon  cloacal." 

Clinical  Features. — The  most  important  clinical  manifestation  of 
uncomplicated  epispadias  is  incontinence  of  urine.  The  incontinence  is 
not  usually  complete  ;  but  any  sudden  movement  or  change  in  position  is 
followed  by  a  gush  of  urine  from  the  small  bladder.  As  a  result  the 
external  genitals  are  kept  constantly  wet,  erosions  soon  appear  upon  them, 
and  the  condition  of  the  patient  is  most  distressing.  Menstruation,  how- 
ever, commonly  occurs  normally,  and  the  woman  may  become  pregnant 
and  bear  a  child.  The  cure  of  the  condition  is,  therefore,  urgently  called 
for,  and  by  paring  the  edges  of  the  parts,  and  uniting  them  by  sutures, 
a  good  result  is  sometimes  obtained.  In  many  instances,  however,  the 
operation  fails  for  want  of  sufficient  tissue,  or  on  account  of  breaking 
down  of  the  union  artificially  brought  about.  In  such  cases  we  have  to 
fall  back  upon  the  use  of  a  carefully  fitted  urinal,  by  means  of  which 
the  patient's  condition  is  rendered  bearable.  This  was  all  that  could 
be  done  for  the  case  seen  by  me. 

Malformations  of  the  Clitoris  and  Labia. —  Pathology.  —  It  has 
been  shown  in  the  preceding  pages  how  the  vulva  may  be  malformed 
in  all  its  component  parts ;  bn.t  it  must  now  be  added  that  each  of  the 
external  genital  organs  may  alone  be  the  subject  of  an  anomaly. 
The  clitoris,  for  example,  may  be  entirely  wanting.  This  happens 
sometimes  in  connection  with  epispadias ;  but  it  is  then  more  usual 
to  find  it  bifid.  Possibly  split  clitoris  in  the  female  is  homologous 
with  the  rare  cases  of  bifid  or  double  penis  in  the  male  sul)ject. 
In  some  cases  the  clitoris  is  found  to  be  poorly  developed,  but  it 
is  more  common  to  observe  hypertrophy  of  it.  This  (udargement  is 
douV>tless  more  often  acquired  than  congenital,  and  is  tlien  associated  with 
self-abuse;  but  it  may  also  be  present  at  birtli,  \isually  in  association 
with  persistence  of  the  urogenital  sinus,  or  with  uterine  malformations. 
When  hypertrophy  of  the  clitoris  is  also  combined  with  labial  hernia 
of  the  ovaries,  the  resemblance  which  the  individual  liears  to  the  male 
type  is  very  marked. 

The  labia  majora  may  be  absent,  but  this  dfd'oct  is  nearly  always 
associated  with  ectopia  vesicae. 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN   WOMAN     97 


They  may  also  be  adherent  to  each  other,  as  lias  been  already  pointed 
out  under  the  head  of  atresia  vulvae  superhcialis,  or  conglutinatio  labi- 
orum.  The  labia  minora  may  also  be  glued  together,  and  probably  this 
accounts  for  some  of  the  cases  in  which  they  were  said  to  be  wanting ; 
they  may  be  truly  absent,  nevertheless,  in  connection  Avith  epispadias. 
It  has  been  stated  that  they  may  be  increased  in  number,  two  or  three 
folds  having  been  found  in  place  of  one  ;  it  is  quite  certain  that  they 
may  be  increased  in  size,  and  the  deformity  called  the  "Hottentot  apron  " 
is  well  known. 

Clinical  Features.  —  Enlargement  of  the  clitoris  and  labia  gives  rise  to 
irritation  in  the  neighbourhood  of  the  external  genitals,  and  may  thus  be 
the  cause  of  self-abuse  and  of  nervous  troubles.  On  this  account  it  may 
be  necessary  to  amputate  the  clitoris,  or  to  excise  the  nymphse.  In  a 
case  of  my  own  great  benefit  followed  the  excision  of  the  labia  minora  in 
a  highly  neurotic  girl,  who  was  thus  restored  from  a  state  of  chronic 
invalidism  to  one  of  health  and  usefulness. 

Malformatioxs  of  the  Hymex.  —  ]\Iany  of  the  malformations  of 
the  hymen  have  little  clinical  importance,  although  they  are  all  of 
interest  from  the  pathological  standpoint,  and  some  of  them  have 
a  bearing  upon  medico-legal  questions.  There  is  as  yet  no  general 
acceptance  of  any  one  theory  of  the  mode  of  development  of  the 
hymen ;  some  writers  assert  that  it  is  vaginal,  others  that  it  is  vulvar 
in  origin :  but  as  it  may  be  present  Avhen  the  vagina  is  absent,  and 
may  even  be  found  in  hypospadiac  males,  the  facts  are  strongly  in 
favour  of  the  latter  theory.  Indeed,  Pozzi,  by  whom  these  facts  have 
been  prominently  enunciated,  regards  them  as  conclusive.  At  any  rate, 
the  hymen  is  to  be  looked  upon,  not  as  a  "  fixed  "  organ,  but  as  a  devel- 
opmental remnant;  and  it  shows,  therefore,  a  very  large  number  of 
small  anomalies  as  regards  structure,  form,  and  position.  It  consists 
really  of  three  parts,  which  Pozzi  has  named  Iqimen  jyrojier,  pad  of  the 
meatus  urinarius  or  urethral  hymen,  and  male  bridle  of  the  vestibule.  All 
these  parts  I  have  repeatedly  been  able  to  recognise  in  the  new-born 
infant ;  although  in  the  adult  they  are  not  very  distinct.  It  would  seem 
that  the  urethral  hymen,  like  the  hymen  proper,  may  present  abnormal- 
ities ;  and  in  an  infant  at  birth  I  have  seen  an  occlusion  of  the  meatus 
urinarius,  by  what  I  regarded  as  a  fusion  of  the  two  lateral  parts  of  the 
pad  of  the  meatus,  or  hymen  urethra. 

Double  Hymen.  —  The  cases  of  double  hymen  which  have  been 
reported  are  probably  errors  of  interpretation.  What  is  called  a  supple- 
mentary hymen  is  usually  a  perforated  diaphragm  in  the  vagina  a  little 
above  the  level  of  the  normal  hymen.  Two  or  even  three  of  these 
diaphragms  may  exist,  and  they  are  doubtless  due  to  adhesions  formed 
between  the  vaginal  walls  in  feetal  life.  Of  course  in  the  rare  cases  of 
doul)le  vulva  there  may  be  two  hymens,  but  this  is  not  what  is  usually 
meant  by  "  double  hymen." 

Absence  of  the  Hymen.  —  Absence,  like  duplication  of  the  hymen,  is 

H 


98  SYSTEM   OF  GYNAECOLOGY 

an  anomaly  whose  occurrence  is  not  well  established.  In  the  infant  at 
birth  the  membrane  often  consists  of  two  poiiting  lateral  folds  which 
may  easily  be  inistaken  for  the  labia  minora  ;  and  in  this  way  the  notion 
arises  that  the  hymen  is  absent.  Further,  in  certain  cases,  especially  in 
the  negro  race,  the  hymen  is  situated  deeply,  because  the  vestibular 
canal  is  longer  than  normal ;  and  here  again  the  membrane  may  seem 
to  be  wanting.  The  medico-legal  bearing  of  these  facts  in  connection 
with  the  question  of  rape  is  evident. 

Atresia  Hjrmenalis.  —  Pathology.  —  The  occurrence  of  imperforation  of 
the  hymeneal  membrane  is  probably  not  nearly  so  common  as  the  large 
number  of  reported  cases  would  seem  to  show.  Undoubtedly  genuine 
examples  of  atresia  of  the  hymen  are  occasionally  met  with  ;  but  in  the 
majority  of  the  recorded  cases  there  is  evidence  to  lead  us  to  suspect  that 
the  membrane  supposed  to  be  hymeneal  was  really  the  blind  end  of  the 
Milllerian  vagina.  It  is  often  possible,  as  Matthews  Duncan  and  others 
have  shown,  to  find  the  normally  perforate  hymen  pushed  backwards 
and  hidden  to  some  extent  by  the  bulging  of  the  vaginal  sac.  Strictly 
speaking,  cases  of  hymeneal  atresia  are  often  instances  of  atresia  of  the 
lower  part  of  the  vagina ;  or,  as  some  prefer  to  name  it,  of  the  retro-hymen. 
In  another  group  of  cases  adhesion  of  the  labia  minora  gives  rise  to  an 
appearance  resembling  atresia  of  the  hymen ;  and  it  is  only  when  the 
labial  attachment  has  been  divided  that  the  hymen  is  seen  lying  beneath. 
The  pathological  results  of  all  these  conditions  are  the  same :  there  is 
retention  of  vaginal  mucus  in  infancy,  and  of  menstrual  fluid  in  later 
life,  with  consequent  occurrence  of  ha^matocolpos. 

Clinical  Features.  —  In  the  position  of  the  vaginal  orifice  is  found  a 
l)ulging  membrane,  sometimes  of  a  bluish  colour,  which  in  some  degree 
resembles  the  intact  bag  of  membranes  in  a  labour  case,  and  has  even 
been  mistaken  for  it.  This  swelling  has  gradually  increased  from  the 
time  of  puberty,  and  its  appearance  .has  been  accompanied  by  colicky 
pains  recurring  with  increasing  severity  at  intervals  of  a  month,  and  by 
the  absence  of  the  menstrual  discharge.  Sometimes,  also,  the  evacuation 
of  the  bladder  and  bowels  has  been  rendered  difficult  and  painful ;  and  in 
a  few  instances  there  have  been  vicarious  menstrual  haemorrhages.  In 
advanced  cases  a  fluctuating  abdominal  tumour  has  appeared,  the  result 
of  distension  of  the  vagina  with  blood.  On  the  top  of  this  swelling  a 
small  hard  mass  can  sometimes  be  detected ;  this  is  the  undistended 
uterus.  In  other  cases  this  organ  also  has  become  a  blood-sac,  and  in 
such  cases  ha;matocolpos  and  haematometra  coexist. 

Operative  interference  is  always  required  in  these  cases,  for  spon- 
taneous external  rupture  is  uncommon ;  even  when  it  occurs  it  is  un- 
satisfactory, the  evacuation  being  incomplete,  and  often  followed  by 
suppuration  in  the  vaginal  cavity.  It  used  to  be  the  custom  to  puncture 
the  imperforate  hymen  at  one  sitting,  and  then  later  to  make  a  crucial 
incision,  and  fully  evacuate  the  contents ;  for  it  was  thought  that  the 
sudden  escape  of  the  vaginal  contents  might  1)0  attended  by  dangerous 
results.      Hut  this  method  is  apt  to  be  followed  l)y  suppuration  ;  and  it  is 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN    WOMAN     99 

best  to  make  first  a  small  incision  so  as  to  allow  the  blood  slowly  to 
escape,  and  then  at  the  same  sitting  to  enlarge  the  opening,  to  wash  out 
the  canal  thoroughly  with  an  antiseptic  lotion,  and  finally  to  pack  it 
firmly  with  iodoform  gauze. 

Anomalies  in  the  form  of  the  Hymen.  —  Many  anomalies  in  the 
form  of  the  hymen  may  be  met  with,  but  they  are  of  comparatively 
little  practical  importance.  Instead  of  having  its  normal  crescentic 
or  semilunar  shape,  it  may  retain  its  infantile  character;  it  then 
shows  two  lateral  projecting  lips,  which  have  sometimes  been  mis- 
taken for  the  nymphae ;  it  is  then  called  lahiated  or  infundihuliform. 
Sometimes  notches  occur  naturally  in  the  membrane,  which  then  is  called 
the  hymen  denticulatus;  it  is  necessary  to  remember  the  occurrence  of 
these  folds  or  notches,  and  to  distinguish  them  from  the  rents  produced 
by  coitus  or  labour.  Rarely  the  Jimbriatfd  hymen  is  met  with.  The 
orifice  is  usually  situated  nearer  to  the  anterior  than  to  the  posterior 
border  of  the  membrane ;  but  occasionally  it  is  quite  central  —  hymen 
circularis.  Further,  the  opening  may  be  very  large  {falciform),  or  there 
may  be  two  orifices  of  equal  size,  situated  laterally  (hymen  septus).  Yet 
another  form  is  that  in  which  there  are  two  apertures  of  unequal  size, 
and  situated  irregularly  (liymen  hifenestratus,  hymen  hiforis).  A  very 
uncommon  type  is  the  cribriform,  in  which  there  are  many  small  holes 
in  the  membrane  (liymen  crihriformi^). 

Anomalies  in  the  structure  of  the  Hymen.  —  Pathology.  —  The  hymen 
maybe  abnormally  thick,  abnormallj^  firm  or  rigid,  or  abnormally  vascular. 
It  may  also  show  combinations  of  these  anomalies.  Thus  it  may  be 
l)oth  thick  and  vascular,  or  both  rigid  and  fleshy.  To  a  certain  extent 
these  states  may  be  regarded  as  due  to  a  persistence  of  the  foetal  char- 
acters of  the  membrane,  and  they  are  of  some  clinical  importance. 

Clinical  Features.  —  Abnormal  rigidity  of  the  hymen  maybe  the 
cause  of  dyspareunia,  or  it  may  entirely  prevent  penetration  in  the  act 
of  coitus.  In  a  case  seen  by  myself  it  was  found  necessary  to  excise 
the  hymen  of  a  newly  married  patient  before  complete  connection  could 
be  accomplished  by  her  husband.  In  other  cases  pregnancy  occurs  not- 
withstanding the  unruptured  state  of  the  hymen ;  and  the  presence  of 
the  membrane  may  protract  laboui-,  or,  if  it  be  torn,  may  cause  a  deep 
laceration  also  of  the  perineum.  Cases  have  even  been  reported  in  which 
the  hymen  has  been  found  intact  after  a  miscarriage ;  but  in  these 
instances  the  membrane  has  probably  been  abnormally  elastic,  rather  than 
abnormally  rigid.  The  importance  of  the  occurrence  from  the  medical 
j  urist's  standpoint  is  manifest  in  connection  with  the  question  of  chastity. 
.Vbnormal  vascularity  of  the  membrane  is  also  an  anomaly  of  some  im- 
portance, for,  on  the  first  occasion  of  coitus,  it  may  be  the  cause  of  alarm- 
ing or  indeed  of  dangerous  haemorrhage.  All  these  structural  malfor- 
uuxtions  of  the  hymen  are  more  easily  understood  if  it  be  granted,  as 
I'ozzi  affirms,  that  the  hymen  is  the  homologue  of  the  corpus  spongiosum 
uf  tlie  male. 


SYSTEM  OF  G\\\L-ECOLOGY 


Hermaphroditism 

Tlie  exact  meaning  of  the  Avorcl  '•'  hermaphrodite,"  as  applied  to  the 
human  subject,  has  undergone  a  change.  Whilst  the  older  writers  applied 
the  term  to  individuals  whom  they  regarded  as  possessing  the  organs 
of  both  sexes  in  an  anatomical  and  in  a  physiological  sense,  modern 
authors  have  come  to  use  the  name  rather  to  indicate  subjects  whose 
true  sex  is  doubtful.  Malformations  of  the  genital  organs,  giving  rise 
to  doubts  as  to  the  true  sex  of  the  individual,  have  attracted  the 
attention  of  observers  from  the  earliest  periods  of  the  world's  history, 
and,  as  I  have  elsewhere  shown  (327),  records  of  such  cases  have  been 
found  on  the  brick  tablets  of  the  ancient  Chaldean  libraries.  In  Rome 
individuals  of  doubtful  sex  were  destroyed.  In  the  East,  on  the  other 
hand,  there  is  reason  to  believe  that  they  were  deified.  According  to 
the  Talmud,  Abraham  was  a  hermaphrodite,  and  so,  according  to  many 
authors,  Avas  Adam. 

In  one  sense  the  human  embryo  at  a  certain  period  of  its  existence 
may  be  regarded  as  hermaphrodite.  There  is  a  stage  in  development 
when  it  is  impossible  to  state  whether  the  sexual  gland  will  become  an 
ovary  or  a  testicle  ;  whether  the  Miillerian  or  the  Wolf&an  ducts  will 
atrophy ;  whether  the  genital  tubercle  Avill  become  a  penis  or  a  clitoris. 
The  embryo  is  then,  so  far  as  is  known,  potentially  of  either  sex,  and 
awaits  the  action  of  some  force  to  determine  which  sex  is  to  predominate. 
It  is  easy  to  understand  how  morbid  influences,  brought  to  bear  upon  the 
embryo  at  or  about  the  time  when  it  is  passing  from  its  sexually  indiffer- 
ent stage  into  one  of  differentiation,  may  so  upset  the  normal  process  of 
development  as  to  produce  an  individual  with,  for  example,  testicles  and 
a  uterus.  It  is,  however,  a  matter  of  great  difficulty  to  imagine  a  con- 
dition of  affairs  which  would  give  rise  to  the  presence  of  a  testicle  and 
an  ovary  on  the  same  side  ;  for,  so  far  as  is  known,  the  sexual  gland  may 
become  either  a  testicle  or  an  ovary,  but  not  both.  In  the  Miillerian 
and  Wolffian  ducts,  on  the  other  hand,  we  have  to  do  Avith  two  sets  of 
structures,  one  of  which  normally  atrophies  and  the  other  develoj)S ;  but 
abnormally  both  may  persist  in  a  more  or  less  fully  formed  condition. 
As  a  matter  of  fact,  it  is  very  doubtful  whether  a  genuine  case  of  the 
coexistence  of  testicles  and  ovaries  in  the  human  subject  has  ever  been 
reported  ;  whilst  instances  of  ])seudo-hermaphroditism,  as  tliey  have  been 
calkul,  are  far  from  rare.  Still,  it  is  never  safe  to  say  that  the  occur- 
rence of  any  particular  toratological  combination  is  impossil)le ;  and  if 
we  bear  in  mind  that  true  hermaphroditism  has  been  met  with  in  fish, 
amphibians,  and  even  in  the  goat  and  pig,  it  may  be  that  some  observer 
will  yet  record  an  undoubted  case  in  the  human  subject. 

Writers  have  classified  cases  of  hermaphroditism  in  various  ways. 
Klebs,  for  example,  divides  them  into  two  grou])S  :  true  heruiapliroditism, 
or  h(>rmaphroditismus  vptus,  in  which  ovaries  and  testicles  coexist;  and 
pseudo-hermaphroditism,  or  hfrmaphroditismus  spurins,  in  which,  along 


MALFORMATIONS   OF  THE    GENITAL    ORGANS  IN   WOMAN     loi 

with  either  ovaries  or  testicles,  there  are  found  some  of  the  genital  organs 
of  the  opposite  sex.  Pseudo-herraaphroditisni,  again,  he  divides  into  mas- 
culine or  feminine,  according  as  testicles  or  ovaries  are  present ;  whatever 
may  be  the  state  of  the  other  reproductive  organs.  Pozzi  to  some  extent 
modifies  this  scheme  of  classification.  He  arranges  all  the  cases  in  three 
groups:  partial pseudo-liermaphroditifim,  in  which  one  sex  obviously  pre- 
dominates, only  a  few  of  the  peculiarities  of  the  other  being  present ; 
pseudo-he  rmaph  rod  it  ism  jvoperly  so-called,  including  a  large  number  of 
cases  chiefly  of  the  variety  known  as  male  hypospadiacs ;  and  supposed  true 
hermaplirodilisra,  in  which  both  kinds  of  sexual  glands  have  been  regarded 
as  present.  It  does  not  seem  theoretically  necessary  to  make  a  distinction 
between  pseudo-hermaphroditism  and  the  partial  variety,  although  practi- 
cally the  separation  may  be  of  value.  The  scheme  here  adopted  is  that 
which  groups  all  the  cases  into  pseudo-hermaphrodites  and  supposed  true 
hermaphrodites,  Avith  certain  subdivisions  which  will  be  stated  under 
each  head ;  and  I  have  added  a  ncAV  variety,  or  rather  have  resuscitated 
an  old  one,  in  which  the  external  genitals  of  both  sexes  seem  to  be  pres- 
ent in  the  same  individual.  Something  will  first  be  said  regarding  the 
cases  which  have  been  reported  as  instances  of  true  hermaphroditism, 
and  then  the  large  group  of  the  pseudo-hermaphrodites  will  be  considered. 

Supposed  Trfe  Hermaphroditism. — Klebs  has  divided  true  her- 
maphroditism into  three  groups  :  bilateral  (or  vertical),  in  which  an  ovary 
and  a  testicle  are  found  on  both  sides  of  the  body;  unilatercd,  in  which 
an  ovary  and  a  testicle  coexist  on  one  side,  whilst  on  the  other  side 
is  an  ovary  or  a  testicle,  or  neither;  and  lateral  (or  alternate),  in 
which  the  female  gland  is  present  on  one  side  and  the  male  on  the 
other.  In  the  present  state  of  our  knowledge  this  subdivision  is,  as 
regards  the  human  subject  at  any  rate,  quite  luinecessary ;  for  well- 
authenticated  examples  of  the  first  and  second  varieties  are  Avanting, 
and  even  of  the  third  type  the  instances  that  have  been  reported  are 
not  altogether  convincing.  All  the  cases  in  which  there  is  no  report  of 
a  post-mortem  examination  are,  of  course,  useless  in  classification ;  for 
the  whole  value  of  such  reports  consists  in  the  recognition  by  the  naked 
eye  and  microscopically  of  tAvo  glands,  one  of  AAdiich  must  have  the  char- 
acters of  the  ovary  and  the  other  those  of  the  testicle.  It  cannot  even 
be  safely  asserted,  as  was  done  by  Rokitansky  in  the  case  of  Catherine 
Hoffmann,  that  the  allegation  of  a  menstrual  discharge  is  a  proof  of  the 
existence  of  ovaries.  Indeed  there  is  evidence  to  sIioav  that  the  adult 
subjects  of  these  abnormalities  Avill  intentionally  mislead  the  observer 
concerning  such  phenomena  as  menstruation. 

The  case  reported  in  1S70  by  C.  L.  Heppner  of  St.  Petersburg  has 
been  regarded  l)y  many  authors  as  a  genuine  exam|)le  of  hermai)hro- 
ditismus  verus  bilateralis  ;  for  in  it  AA-ere  descrilied  a  uterus  Avith  ovaries 
and  tubes,  and  on  each  side  also  a  rounded  body  in  the  neighbourhood 
of  the  ovary  Avhich  had  the  microsco])ical  charactors  of  the  testicle. 
The  external  organs  A^rere  like  those  of  the  Avt)man.     Xoav.  Avith  regard 


SYSTEM   OF  GYNECOLOGY 


to  this  case,  it  must  be  borne  in  mind  that  the  parts  had  been  pre- 
served for  some  time  in  spirit  before  they  were  examined ;  and  that 
the  microscopical  appearances  of  the  so-called  testicles  might  easily 
be  regarded  as  those  of  immature  or  undifferentiated  ovaries.  The 
arrangement  of  tubes  packed  with  cells,  as  depicted  by  Heppner, 
seems  to  me  to  suggest  a  mal-developed  ovary  as  much  as  a  testicle. 
The  probability  is  that  the  so-called  testicles  were  really  accessory  or 
constricted  ovaries  —  bodies  which,  as  has  already  been  stated,  often 
show  a  structure  made  u.p  almost  entirely  of  Pfliiger's  tubes.  The  case 
examined  by  H.  j\[e3'er,  and  reported  by  Cramer  in  1857,  is  one  of  a 
considerable  number  in  Avhich  true  hermaphroditism  of  the  lateral 
variety  was  alleged  to  be  present.  In  this  instance  there  were  a  rucli- 
mentar}'  uterus  and  a  vagina,  and,  on  the  right  side,  a  normal  ovary, 
parovarium,  and  tube.  On  the  left  side  were  a  tube,  a  parovarium,  and 
a  body  herniated  in  the  left  scrotal  sac,  and  supposed  to  be  a  testicle. 
Cramer  does  not  give  the  detailed  microscopical  appearances  of  this 
body ;  but  it  seems  more  rational  to  regard  it  as  an  ovary,  possibly  in  a 
rudimentary  state,  which  had  descended  into  the  left  labium,  than  as  a 
testicle.  In  conclusion,  it  may  be  said  that  science  still  awaits  the 
publication  of  a  case  in  which  all  competent  observers  will  be  able  to 
recognise  the  existence  in  the  same  individual  of  two  glands,  one  of 
which  is  undoubtedly  ovarian  and  the  other  testicular  in  nature.  In  the 
meantime  it  seems  impossible  to  conceive  how  the  impulse  that  deter- 
mines sex  can  be  so  divided  in  its  action  as  to  turn  one  sexual  gland 
into  an  ovary  and  the  other  into  a  testicle. 

PsEUDO-HERMAPHRODiTisM. — Pathology. — Cascsof  pseudo-liermapli- 
roditism  are  not  uncommon,  as  a  glance  at  the  appended  bibliograph- 
ical list  (for  the  last  five  years)  will  serve  to  show.  In  many  of  them 
the  dubiety  as  regards  sex  is  evidently  due  to  the  existence  of  one  or 
other  of  the  anomalies  of  the  female  external  genital  organs  which  have 
been  already  described.  In  many  more,  however,  we  have  to  deal  with 
malformations  of  the  penis  and  scrotum,  which  have  given  to  the  exter- 
nal parts  a  somewhat  feminine  appearance.  In  the  former  group  of 
cases  the  ovaries  are  present,  whatever  may  be  the  condition  of  the 
other  organs,  and  the  individual  is  therefore  really  a  female  in  the 
state  known  as  pseuclo-hermaphrocUtismus  femininus  or  gynandry  :  in 
the  latter  group  the  subject  by  the  possession  of  the  testicles  is  a 
male,  however  closely  he  may  approach  the  other  sex  in  appearance, 
a  state  known  as  pseudo-herwaphroditismus  mascuUnns  or  androgyny. 
Individuals  of  the  second  kind  are  far  commoner  than  those  of  the  first. 
Kach  of  these  two  varieties  has  been  subdivided  into  three  groups  — 
InternuH,  externus,  and  completus.  Thus  in  a  case  of  psoudo-hermaphro- 
ditismus  masculinus  internus  there  are  testicles  in  association  with 
external  genitals  of  the  male  ty})e,  and  a  uterus,  vagina,  and  even 
tubes.  In  pseudo-hermaphroditismus  masculinus  externus  there  are  also 
testicles,  but  the  external  genitals  and  the  build  of  tlm  body  are  feminine. 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN   WOMAN     103 

Again,  in  pseudo-hermapliroditismus  masculinus  completus  seu  externus 
et  internus  there  are  testicles,  but  there  is  also  a  uterus  masculinus  with 
tubes;  and  the  external  organs  approach  more  or  less  closely  to  the 
female  form.  In  the  same  way  in  the  three  varieties  of  feminine  pseudo- 
hermaphroditism there  are  always  ovaries;  but  in  the  internal  type  there 
are  also  distinct  traces  of  the  Wolffian  ducts ;  in  the  external  type  the 
external  genitals  are  of  the  male  form ;  and  in  the  complete  type  the 
external  organs  are  masculine,  and  the  Wolffian  ducts  and  prostate 
gland  are  present.  The  enumeration  of  these  varieties  will  have  given 
the  reader  some  idea  of  the  morbid  anatomy  of  pseudo-hermaphrodit- 
ism ;  at  the  same  time  it  must  be  borne  in  mind  that  some  of  them  are 
very  rare  ;  one  of  them,  on  the  other  hand  —  pseudo-hermaphroditismus 
masculinus  externus  —  is,  comparatively  speaking,  very  common. 

One  of  the  most  usual  arrangements  of  parts  to  which  the  name  of 
feminine  pseudo-hermaphroditism  is  given  is  that  in  which  a  woman 
presents  an  adhesion  of  the  labia  along  with  hypertrophy  of  the  clitoris. 
When,  also,  there  is  a  labial  ovarian  hernia  on  one  or  both  sides,  and 
a  development  of  hair  on  the  face,  the  resemblance  to  the  male,  at 
any  rate  to  the  hypospadiac  male,  becomes  very  striking.  The  vulva, 
however,  may  be  normal,  and  the  subject  show  simply  an  enlarged 
clitoris,  a  beard,  and  a  masculine  arrangement  of  the  pubic  hair,  as  in 
the  case  of  Zefthe  Akaira  (La  Donna-Uomo),  recently  described  by  Zuc- 
carelli  in  Italy.    Examples  of  this  kind  of  gynandry  might  be  multiplied. 

Non-descent  of  the  testicles  in  the  male  gives  origin  to  one  variety  of 
androgyny.  Such  men  are  often  the  subjects  of  gynaecomastia  (enlarge- 
ment of  the  breasts) ;  and  since  also  the  penis,  although  perforate,  is  some- 
times small,  and  the  sexual  functions  poorly  developed  (infantilism),  it  is 
easy  to  understand  how  doubts  as  to  their  virility  may  arise.  A  more 
common  type  of  androgyny,  however,  is  that  caused  by  the  existence  of 
scrotal  hypospadias  (Fig.  39).  In  this  case  the  resemblance  to  the  female 
type  of  external  genitals  is  very  strong,  for  there  is  a  small  imperforate 
penis  often  fixed  in  position  under  the  symphj^sis  by  adhesions ;  the  urethra 
opens  externally  near  the  root  of  the  penis,  and  beloAv  it  is  a  sort  of 
vulvar  aperture  or  vestibular  canal  which  may  even  be  of  some  depth, 
and  may  be  guarded  by  a  hymen.  The  external  genitals  in  such  a  case 
resemble,  as  Pozzi  graphically  expresses  it,  those  of  an  embryo  seen  under 
a  magnifying  glass.  When  it  is  also  borne  in  mind  that  the  testicles 
are  either  undescended  or  at  any  rate  atrophic,  and  that  the  individual 
has  probably  been  mistaken  for  and  brought  up  as  a  girl,  and  has  thus 
acquired  feminine  habits,  it  is  easy  to  see  how  extremely  difficult  it  may 
be  to  ascertain  the  real  sex.  The  difficulty  may  be  still  further  increased 
by  enlargement  of  the  mammre,  by  the  absence  of  hair  on  the  face  and 
chest,  and  by  the  occasional  discovery  of  a  uterus ;  although,  of  course, 
ovaries  are  not  to  be  detected.  Doubtless  most  of  the  cases  of  supposed 
true  hermaphroditism  have  been  really  hypospadiac  men. 

A  word  or  two  may  here  be  said  regarding  a  form  of  pseudo-hermaph- 
roditism   not  recognised  by  recent   writers.     In   very  rare   instances 


104 


SYSTEM-  OF  GYNAECOLOGY 


individuals  otlierwise  apparently  single  show  complete  duplication  of  the 
vulva  or  of  the  penis.  In  a  recent  article  (328)  I  have  shown  that  in  some 
of  these  cases  of  diphallus  one  penis  only  may  be  perforate,  the  other  being 
small,  and  presenting  an  opening  below  it  through  which  urine  escapes. 


W^ycr^jy^ 


Fig.  .".f*.  —  ]'scMi(lo-li(tririii|)l]r(iilili.iiii,  iiciincosi'nilal  liy|Mi.s|iiiiliiis.  (AI'Ut  Pozzi.)  f/,  CJliins;  /;,  tVn^iiiini  ; 
ran,  meatus  uriiiarlus  ;  or.,  viilviir  oi-i/lcc  ;  /(//,  liyiiicii  ;  /'  /uufclicttc  ;  yy/,  liiltiii  minora;  (//,  labia 
mnjora. 

Sufli  a  case  might  easily  bo  regarded  as  an  instance  of  the  coexistence  of 
Ijoth  male  and  female  external  genitals ;  and  ])ossibly  some  of  the  dis- 
credited accounts  of  ])ersons  provided  with  a  vulva  and  a  penis,  reported 
by  early  writers,  may  have  Ijelongcd  to  this  category.     Similarly  in 


MALFORMATIONS    OF   THE    GENITAL    ORGANS  IN   WOMAN     105 

individuals  with  a  double  vulva  the  enlargement  of  one  clitoris  might 
give  rise  to  a  similar  notion  ;  and  probably  the  case  of  an  infant,  seen  by 
Moostakov,  in  which  there  were  on  one  side  external  genitals  of  the 
female  type  with  a  perforate  urethra,  and  on  the  other  an  imperforate 
penis  (?)  and  a  scrotum  without  testicles,  may  have  been  of  this  kind. 
The  condition  might  be  called  external  x^seudo-keriaaphroditism,  had  not 
this  name  been  already  appropriated  to  another  type  of  genital  anomaly. 

Clinical  Features. — AVhilst  in  the  histories  of  pseudo-hermaphrodites 
there  are  many  details  which  are  peculiar  to  each  case,  there  are  also  some 
which  are  practically  common  to  all.  The  error  in  the  recognition  of  the 
true  sex  of  the  individual  is  usually  made  at  birth  and  confirmed  at 
baptism ;  and,  as  a  rule,  it  is  not  till  the  period  of  puberty  is  reached 
that  doubts  of  the  accuracy  of  the  declaration  at  birth  begin  to  prevail. 
In  the  case  of  male  pseudo-hermaphrodites  the  error  may  even  be  per- 
petuated still  longer,  and  the  individual  may  be  married  as  a  woman  and 
live  with  a  husband,  an  imperfect  form  of  coitus  taking  place  per  urethram. 
Usually,  however,  suspicions  begin  to  be  entertained  at  puberty  when, 
in  the  case  of  hypospadiac  males  who  have  been  brought  up  as  females, 
the  failure  of  the  establishment  of  the  menstrual  function  and  the  appear- 
ance of  certain  of  the  secondary  sexual  characters  proper  to  the  male  sex 
give  rise  to  doubts.  At  the  same  time,  it  must  be  borne  in  mind  that 
even  in  these  subjects  hgemorrhage  simulating  the  menses  may  take  place 
from  the  urethra  dilated  by  coitus,  and  in  a  f  cav  instances  a  real  catamenial 
discharge  from  a  uterus  has  been  noted.  Further,  the  secondary  sexual 
characters  cannot  be  relied  upon ;  for  mammary  enlargement,  rounded 
outlines,  a  broad  pelvis,  a  small  larynx,  and  a  feminine  distribution  of  the 
body-hair,  may  all  be  met  within  male  pseudo-hermaphrodites,  Avhilst  the 
secondary  sexual  characters  of  the  male  may  coexist  with  ovaries.  The 
habits,  also,  and  the  feelings  anddesires  of  the  subj  ect,  will  dependlargely  on 
the  surroundings  of  early  life,  and  cannot  be  regarded  as  diagnostic  of  the 
sex.  Pseudo-hermaphrodites  are  generally  sterile ;  for  the  sexual  glands 
are  often  mal-developed,  and  even  when  they  are  active  the  anomalies  of 
the  other  organs  prevent  the  successful  accomplishment  of  the  reproduc- 
tive act.  Mental  and  moral  weakness  and  even  insanity  are  not  uncommon ; 
and  in  the  case  of  Alexina  B.,  so  graphically  recorded  by  Tardieu,  the 
individual,  a  hypospadiac  male,  committed  suicide.  Many  of  the  so-called 
"  degenerates  "  show  anomalies  of  the  genital  organs.  That  the  condition 
may  be  hereditarily  transmitted  is  probable ;  at  any  rate  family  prevalence 
is  not  uncommon,  and  J.  Phillips  has  recently  reported  four  cases  of 
pseudo-hermaphroditism  in  one  family  and  Lindsay  has  seen  three.  I 
am  also  acquainted  with  a  case  in  which  two  hypospadiac  males,  the 
children  of  one  mother,  have  been  brought  up  as  sisters. 

The  treatment  of  such  cases  presents  many  puzzling  problems.  Law- 
son  Tait's  rule  that  every  infant  about  whose  sex  there  is  doubt  should  be 
brought  up  as  a  male  is  a  good  one;  for  male  pseudo-hermaphrodites  are 
more  common  than  female,  individuals  reared  as  males  are  not  so  apt  to 
enter  into  marriasre  in  ignorance  of  their  sexual  inabilitv.  and  there  is  less 


SYSTEM   OF  GYX.ECOLOGY 


danger  in  bringing  up  a  girl  among  boys  than  a  boy  among  girls.  The 
question  of  the  advisability  of  surgical  interference  is  a  difficult  one.  In 
a  case  reported  by  Christopher  Martin,  the  testicles  were  removed  from  an 
individual  brought  up  as  a  girl,  and  castration  was  followed  by  a  develop- 
ment of  the  breasts  and  pubic  hair ;  whilst  Pean  records  the  extraordinary 
operative  history  of  an  individual  whose  abdomen  was  first  opened  to 
discover  the  sex,  then  an  artificial  vagina  was  made,  and  finally  the 
abdomen  Avas  again  opened  and  the  tubes  and  ovaries  removed.  The 
division  of  a  tight  frenum  in  a  hypospadiac  male,  and  the  separation  of 
the  adherent  labia  in  a  gynandrous  individual,  are  minor  operations  which 
may  be  undertaken  without  hesitation ;  but  it  is  doubtful  whether  we 
are  justified  in  removing  the  sexual  glands  in  any  case  of  pseudo-her- 
maphroditism,  although  of  course  the  alternative  procedure  of  making 
a  redeclaration  of  sex  is  also  attended  with  difficulty  and  great  incon- 
venience. Possibly  it  may  be  well  to  consider  the  advisability  of  the  estab- 
lishment of  a  third  class  of  individuals,  who  shall  be  regarded  as  neuter. 
The  medico-legal  bearings  of  hermaphroditism  are  self-evident.  The 
questions  of  identity,  of  paternity,  of  the  right  to  exercise  the  franchise, 
and  to  enter  professions  open  only  to  one  sex,  when  the  individual  is  one 
about  whose  true  sex  there  is  some  doubt,  all  require  very  careful  con- 
sideration and  clinical  investigation.  Further,  the  legality  of  a  mar- 
riage between  a  man  and  a  hypospadiac  male  cannot  be  maintained ; 
and  one  between  a  woman  and  a  gynander  is  equally  against  the  law. 
Further  consideration  of  these  matters  is  not,  however,  necessary  in  a 
text-book  of  gynsecology. 

J.  W.  Ballantyne. 

RECENT  REFERENCES 

Malformations  of  the  Ovaries:  —  1.  Ballantyne  and  Williams.  Structures 
in  the  3fesosalpinx,  p.  44,  189.3.  —  2.  For  early  bibliographical  references  vide 
Olshausex.  Die  krunkheiten  der  Ovarien,  p.  12.  Stuttgart,  1877.  —  3.  Winckel. 
Lehrbuchder  Frauenk7-ankheiten,  p.  595.  Leipzig,  188().  —  4.  Colomiatti,  V.  Frammenti 
di  er/ibriolof/ia  patolofjica,  \).  li.  Torino,  1880. — 5.  Keppler.  AUg.  Wien.  nied.  Ztg. 
p.  .38.5,  1880.-0.  HoMANS,  .J.  Boston  M.  and  S.  Journ.  cxvii'.  p.  .TO,  1887.— 7. 
Sippkl,  A.  Cfln«raZ6L/.  G-';/?i«^.  xiii.  p.  .305,  1889. — 8.  Bassini.  Centralbl.f.  Grjnak. 
xiii.  p.  <;40,  1889.-9.  Ballantyne,  J.  W.  Trans.  Kdin.  Ohst.  Soc.  xv.  p.  5(>, 
1890.  — 10.  Tait,  Lawson.  Diseases  of  Woiwu,  i.  p.  277,  1889. —  11.  Schantz,  H. 
"  Vier  Fallc  von  accessorischen  Ovarien," />is.s.  Kiel,  1891.  — 12.  Falic,  E.  Berl.klin. 
Wchnschr.  No.  44,  1891.— 1.3.  Mundb.  Am.  Journ.  Obst.  xxiv.  p.  218,  1891.— 14. 
Sutton,  J.  Blano.  Surfiical  Diseases  of  the  Ovaries,  e<c.,p.  24.  London,  1891.  — 15. 
Skkne,  a.  J.  C.  Diseases  of  Women,  2nd  edit.  p.  4.50,  1892.  — 1(!.  Popoff,  D.  Arch, 
f.  Gynaek.  xliv.  p.  275,  1893.-17.  Zinnin,  A.  La  mM.  infant,  i.  p.  2()7,  1894.  — 18. 
Rupi'OLT,  E.  Arch.f.  (r(/?ir/p/t-.  xlvii.  p.f)4(),  1894.  — 19.  Dklagi';nierk,  P.  Pror/r.  rndd. 
2iid  series,  ii.  p.  2.5(i,  1894.-20.  EDiuofiR-GRKKN,  F.  W.  lirit.  Med.  .Jonrn.  p.  41(),  i.  for 
1895. — 20'<.  Encstrom.  Finska  liikar.  hondli/n/ar,  xxxvii.  p.  ()(i7,  1895. — '2()b. 
M'CosH,  A.  F.  Trans.  Am.  Surg.  A.fsoc.  xiii.  p.  481,  1895.  —  20c.  Lockwood,  C.  B. 
lirit.  Med.  Journ.  p.  71G,  ii.  for  1895. 

Malformations  of  the  Fallopian  Tubes:  —  21.  Richard,  A.  Compt.  rend.  Soc.  de 
hiol.  iii.  p.  :;7,  18.52. —22.  Br,oT.  Ibid.  2nd  series,  ill.  p.  176,  1857.-2.3.  HUter,  C. 
Mori.ats.  /'.  dcbnrlsk.  xxv.  p.  424,  1805.  —  24.  Stevv'Art,  T.  (x.  Jour.  Anat.  and 
Physio/.  'U.  p.  24.3,  1808. —25.  Keppler.  Allg.  Wien.  med.  Ztg.  p.  .385,  1880.-20. 
Colo.miatti,    V.     FrauuiuuUi    di    embriologia    patologica,   p.    14.     T(jrino,    1880.  —  27. 


MALFORMATIONS    OF  THE    GENITAL    ORGANS  IN   WOMAN     107 

SiNKTY,  L.  DE.  TraiU  pratique  de  (hjnecolor/ie,  p.  770,  1881.  — 28.  Winckel,  F. 
Lehrhuch  der  Frauenkrcmkheiten,  p.  5(i9.  Leipzig,  1886. —  29.  Doran,  A.  Trans. 
Obst.  Soc.  London,  xxviii.  p.  171,  1887.  — ao.  Ballantyne,  .J.  W.  Trans.  Edin. 
Obst.  Soc.  XV.  p.  56,  1890.-31.  H.\ultain,  F.  W.  N.  Trans.  Edin.  Obst.  Soc.  xv. 
p.  220,  1890.-32.  Ballantyxe,  J.  W.,  and  Willi^vms,  J.  D.  Brit.  Med.  Journ. 
.Jan.  17  and  24,  1891.— :io.  Falk,  E.  Berl.  klin.  Wchnschr.  No.  44,  1891.  — 34. 
Sutton,  .J.  Bland.  Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes,  p.  227. 
London,  1891.-35.  Haultain,  F.  W.  N.  Trans.  Edin.  Obst.  Soc.  xvii.  p.  194, 
1892. —  36.  Amann,  J.  A.  Arch.  f.  Gynaek.  xlii.  p.  133,  1892.  — 37.  Popoff,  D. 
Arch.  f.  (ixjnaek.  xliv.  p.  275,  1893.  — 38.  Ballantyne,  J.  W.,  and  Williams,  J.  D. 
The  Structures  in  the  Mesosalpinx,  p.  25.  Edinburgh,  1893. —  39.  Marchand.  Berl. 
klin.  Wchjischr.  p.  814,  Aug.  27,  1894. —  40.  Ruppolt,  E.  Arch.  f.  Gynaek.  xlvii.  p. 
616,  1894. — 41.  Kossmann.  Ztschr.  f.  Geburtsh.  u.  Gyndk.  xxix.  p.  253,  1894. — 
42.  FERR.4.RESI,  C.  Ann.  di.  Ostet.  xvi.  p.  521,  1894. — 43.  Delageniere,  P. 
Prof/res  m^d.  2nd  series,  ii.  p.  256,  1894. — 44.  Sanger,  M.  Monatschr.  f.  Geburtsh. 
u.  Gynaek.  i.  p.  21,  1895.— 45.  Edkidge-Green,  F.  W.  B7'it.  Med.  Journ.  p.  416,  i. 
for  1895.  —  46.  Kube,  N.  N.  Journ.  akush.  i  jensk.  boliez.  p.  485,  May  1895. — 46a. 
Penrose.  Am.  Journ.  Obst.  xxxii.  p.  295,  1895. — 466.  Sanger.  Centrulbl.f.  Gynlik. 
XX.  p.  162,  1896. 

Uterus  Accessorius: — 47.  Skene,  A.  J.  C.  Treatise  on  the  Diseases  of  Women, 
p.  29,  1892.-48.  Hollander,  E.  Berl.  klin.  Wchnschr.  xxxi.  p.  452,  1894. —49. 
Depage.     Arch,  de  tocol.  xxi.  p.  550,  1894. 

Uterus  Didelphys  et  Bicomis  :  — 50.   Althen.     Centralbl.f.  Gyniik.  xiv.  p.  711, 1890. 

—  51.  Paschen.  Centralbl.  f.  Gyniik.  xiv.  p.  11,  1890. — 52.  Dudley.  Am.  J. 
Obst.  Jan.  and  Feb.  1890. — .53.  Schuler,  C.  "  Ueber  einen  Fall  von  Uterus  duplex 
septus  cum  vagina  septa,"  i)is.s.  Kiel,  1890. — 54.  Gusserow.  Cha7it^'Ann.  xv. -p.  618, 
1890. — 55.  Thevard.  iV.  Arch,  d'obst.  et  de  gynec.  v.  p.  640,  1890. — 56.  Elbing,  R. 
iS7.  Petersb.  med.  Wchnschr.  vii.  p.  299,  1890.  —  ."i7.  Vasten,  V.  A.  Bolnitsch.  gaz. 
Botkina.  i.  p.  986,  1890.  —  58.  Ballantyne,  J.  W.  Trans.  Edin.  Obst.  Soc.  xv.  p. 
160,1890.-59.  ScHWARZ.  Frauenarzt,  vi.  p.  12,  1891.  — 60.  Broome,  G.  W.  Weekly 
M.  Rev.  xxiii.  p.  321,  1891.  —  61.  Massey,  G.  B.  Ann.  Gynsec.  and  Pxdiat.  iv.  p.  365, 
1890-1.-62.  HiRiGOYEN.  Rev.  obst^t.  et  gynic.  vu.  p.  loZ, 1891. — 1)3.  CrRATULO,  G.  E. 
Riforma  med.  vii.  p.  337,  1891.-64.  Ciajo,  A.  Guzz.  d.  osp.  xii.  p.  670,  1891.  —  65. 
NiTOT.  Rev.  obst^.  et  gynec.  vii.  p.  340,  1891.  —  66.  Layton,  R.  N.  Orl.  M.  and  S.  J. 
xix.  p.  412,  1891-2.-67.  Schwartz,  F.  Orvosi  hetil.  xxxv.  p.  294,  1891.-68. 
Berlin,  F.  Ann.  Gynsec.  and  Pxdiat.  v.  p.  193, 1891-2.  —  69.  Halter,  G.  Wien.  med. 
P?'es.9e,  xxxiii.  p.  49,  1892.  —  70.  Tannen,  A.  Centralbl.  f.  Gyniik.  xvi.  p.  51,  1892. — 
71.  Sacks,  G.  Med.  Obozr.  xxxvii.  p.  130, 1892.  —72.  Burke,  W.  H.  Brit.  Med.  Journ. 
i.  for  1892,  p.  1020.-73.  Williams,  F.  N.  Lancet,  i.  for  1892,  p.  1185.-74. 
Drujinin,  I.  N.  J.  akush.  i  jensk.  boliez.  vi.  p.  239,  1892.  —  75.  Giglio,  G.  Rifoi-ma 
msd.  viii.  p.  185,  1892.— 76.  Sicherer,  O.  v.  Arch.  f.  Gynaek.  xlii.  p.  339,  1892.-77. 
PiccoLi,  G.  Levatrice  mod.  i.  p.  58,  1892. — 78.  Borde,  L.  Bull.  d.  sc.  med.  di 
Bologna,  iii.  206,  1892  (3  cases).  — 79,  Stoll,  K.  Ztschr.  f.  Geb.  and  Gyn.  xxiv.  p.  275, 
1892.-80.  RossA,  E.  Wien.  klin.  Wchnschr.  v.  p.  501,  1892.-81.  Stewart,  W.  S. 
Ann.  Gynmc.  and  Pxdiat.  vi.  p.  150, 1892-3.-82.  Currier,  A.  F.  X.  Y.  Journ.  Gynxc. 
and  Obst.  iii.  p.  50,  1893.  —  83.  Edebohls,  G.  M.  iV.  Y.  Journ.  Gynxc.  and  Obst.  iii.  p. 
290,  1893.  — 84.  Stratz,  C.  H.  Nederl.  Tijdschr.  v.  Verlosk.  en  Gynaec.  iv.  p.  121, 
1893.-85.  BiEHL,  K.  Mitth.  d.  Ver.  d.  Aerzte  in  Steiermark,  xxx.  p.  103,  1893.-86. 
Kleinwachter,  L.  Zeitschr.  f.  Geb.  u.  Gyn.  xxvi.  p.  144,  1893.-87.  Cullixgworth, 
C.J.  Trans.  Am.  Gyn.  Soc.  xviii.  p.  434,  1893.  — 88.  R.\t(lifek,  J.  R.  Trans.  Obst. 
Sor.  Lond.  xxxiv.  p.' 469,  1893.-89.    Leuf,  A.  H.  P.     Med.  \eirs,  Ixiii.  p.  4!0,  1893. 

—  90.  Senfft,  a.  Ztschr.  f.  iirztl.  Landprayis,  ii.  p.  313,  1893.  — 91.  Johx.son,  F. 
W.  Boston  M.  and  S.  J.'cxx\x.  p.  643.  1893.-92.  Pfannexstiel,  J.  Festschrift 
.  .  .  in  Berlin,  p.  .330,  1894.  — 93.  Luhleix,  H.  Centralbl.  f.  Gyniik.  xviii.  p.  997, 
1894. —94.  Croasdale,  H.  T.  .■!/». ,;".  O/j.-i^  p.  359,  1894.  — 95.  Semeleder,  F.  Gac. 
m4d.  Mexico,  p.  287,  1894.-96.  Caldkrini,  G.  II  Policlinico,  p.  92,  1894.- 97. 
Burton,  J.  E.  Liverpool  Med.-Chir.  J.  p.  4."9.  1894.-98.  Gouget.  A.  Bull.  Sor. 
Anat.  de  Pai-is,  p.  24, 1894.-99.  RossA,  E.  Centralbl.  f.  Gyniik.  xviii.  p.  422, 1894.  —  100. 
Avers,  E.  .\.  Am.  J.  Ob.'^t.  p.  104,  1S94.  — 101.  Eustaphe,  G.  Ann.  di.  Osttt.  p. 
336,  1S94.  — 102.  ScHUHL.  Ann.  de  Gyn^c.  p.  248,  1894.-103.  Werder.  X.  O.  J. 
Am.  M.  Ai^snc.  p.  234,  1894. —  104.  Kixghokx.  Montreal  Med.  Journ.  p.  442,  18!)4.— 
105.   Owen,  R.   O.     Virginia   Med.  Monthli/,  p.  926,   1895.  — 106.   Serejinskv,  C.  P. 


io8  SYST£M   OF  GYNAECOLOGY 

Journ.  akush.  p.  183,  1891. —107.   Simon,  M.     Centralbl.  f.  Gyniik.  xviii.  p.  1313,  1894. 

—  lOS.  Batchelor,  F.  C.  Intercol.  Quart.  J.  Med.  and  Surg.  i.  p.  309,  1895.  — 109. 
Arnoed,  E.  G.  E.    ia/lce^  i.  for  189'),  p.  988.  — 110.   Chapuis.    Zj/oh.  ?»«?.  p.  83,  1894. 

—  111.  RossiER.  Bev.  med.  d?  la  Suisse  7-oina7ide,  p.  li>9,  lii''.)o. -^112.  Eoux.  G.  Arch, 
de  tocol.  p.  59,  1895.— 113.  Swope,  S.  D.  3Ied.  News,  p.  391,  1893.-114.  Penrose,  C. 
B.  Am.  Jown.  Obst.  p.  915,  1893.  — 115.  Maygrier,  Rev.  med.-chir.  d.  mal.  d. 
femmes,  p.  353,  1893.  —  115a.  Mallett,  G.  H.     N.   Y.  Med.   Journ.   l.xiii.  p.  24,  1893. 

—  1156.  Mettexhei-Mer,  C.  Arch.  f.  Gyniik.  1.  p.  221,  1893.  — 113c.  Baer,  B.  F. 
Am.  Gyn.  and  Obit.  Journ.  vii.  p.  40,  1895.  —  l]5rf.  Brull,  P.  Arch,  de  Ginecopat. 
obstet.)/  pediat.  viii.  p.  651,  1893.  —  113e.  Tschudy,  E.  Arch.  f.  Gyniik.  xlix.  p.  471, 
18J5.  — 115/.  Sprigg,  W.  M.  Am.  Journ.  Obst.  xxxii.  p.  78,  1895.  — 115(/.  Eustache, 
G.  Journ.  sc.  med.  de  Lille,  xviii.  p.  313,  1895.  —  115/i.  Goullioud.  Rsv.  obstet  in- 
ternat.  Siippl.  p.  251,  1895.  —  115i.  Griffon,  V.  Bull.  Soc.  Anat.  de  Paris,  5.  s.  ix. 
p.  520,  1893.  —  ll."y.  Meerdervoort,  N.  J.  F.  P.  Ai-ch.  de  tocol.  xxii.  p.  721,  1895. — 
115k.  Spiegelberg,  H.  A7-ch.  f.  path.  Anat.  cxlii.  p.  554,  1895.-115^.  Giles,  A. 
Trans.  Obst.  Soc.  London,  xxxvii.  p.  301,  189G.  —  113;u.  Swayne,  W.  Bristol  Med.- 
Chir.  Journ.  xiv.  p.  101,  1896. 

Uterus  Septus:  — 116.  Schramm,  J.  Centralbl.  f.  Gyniik.  xiv.  p.  185,  1890. 
— 117.  Shtol,  K.  Otchet.  Afar,  ginek.  otdiel,  p.  4:7, 18'31.  — 118.  Scialdoni,  A.  Gior. 
inter naz.  d.  sc.  med.  xiii.  p.  534,  1891.  — 119.  Kleinschmidt.  K.  Univ.-F'i-auenklin. 
in  Miinchen,  p.  129,  1892.-120.  Fuchtenbuch,  H.  Diss.  Strasburg,  1892.-121. 
Drake-Brockmax,  H.  E.  Brit.  Med.  Joiwn.  i.  for  1893,  p.  1220.-122.  Hallow^ell, 
W.  E.  North-west.  Lancet,  xiii.  p.  427,  1893.  — 123.  Wheaton,  S.  W.  Lancet,  ii.  for 
1893,  p.  1562.  — 124.  Chrobak.  Centralbl.  f.  Gyniik.  xviii.  p.  431,  1894.  — 125.  Mert- 
TENS.  Centralbl./.  Gyniik.  xviii.  p.  1001,  1894.  — 126.  Werth,  R.  Arch.  f.  Gynaak. 
xlviii.  p.  422,  1895.  — 127.     Karra,   D.    A.     Universitetskiya  izvyestiya,  p.    14S),   1895. 

—  127a.   Walther,  H.     Ztschr.  f.  Geburtsh.  u.  Gyniik.  xxxiii.  p.  .389,  1895. 

Uterus  Unicornis:  — 128.  Frommel.  Miinchener  med.  Wchnschr.  No.  13,  1890. — 
129.  VoLL.  Sitzungsb.  d.  phys.-med.  Gesellsch.  zu  Wiirzbvrg,  pp.  30,  33,  1891.  — 130. 
Skene,  A.  J.  C.  Treatise  on  the  Diseases  of  Women,  p.  33, 1892.  — 131.  Mangiagalli,  L. 
Alti.  d.  Assoc,  med.  Lombarda,  p.  29,  1892.-1.32.  Tapie.  Midi  med.  i.  pp.  85,  97,  1892. 
— 133.   Gessner.     Centralbl.  f,  Gyniik.  xviii.  p.  824,  1894. 

Uterus  Deficiens  et  Rudimentarius: — 1.34.  Werner,  J.  Deutsche  med.  Wchnschr. 
No.  11,  1890.-135.  Frank,  K.  Ztschr.  f.  Geburtsh.  u.  Gynaek.  xviii.  Hft.  2,  1890. — 
136.  Altmann.  Centralbl.  f.  Gi/niik.  xiv.  p.  103,  1890. — 137.  Liebmann.  Centralbl. 
f.  Gyniik.  xiv.  p.  928,  1890.  — 138.  Rossignol,  F.  Thesis.  Paris,  1890.-139.  Mar- 
CHioNNKSCHi,  O.     Pisa,  1890.  — 140.    Swiecicki,  V.     Wien.  med.  Bl.  xiv.  p.  83,  1891. 

—  111.  LovioT.  Bull,  et  m^m.  sod  obst.  et  gyndc.  de  Pc(ris, -p.  IS,  1S'.)1. — 142.  Balade. 
Journ.  de  niM.  di  Bordeaux,  xxi.  p.  85,  1891-2.  — 143.  DELAGi<;Ni£;RK,  H.  Cong. /raw;, 
de  chir.  Proc.-verb.  Paris,  v.  p.  346,  1891.-144.  Snow,  L.  B.  Med.  Rec.  xli.  p.  41. 
1892.-145.  HoF.MOKL.  Ber.  d.  k.k.  Kraukenanst.  in  Wien,  p.  334,  1891.-146. 
Elischer,  J.  Pest,  med.-chir.  Press",  xxviii.  p.  274,  1892.  — 147.  Brettauer,  J.  Am. 
J.  Obst.  xxvi.  p.  .394,  1892.  — 148.  La  Torre,  F.  Bull.  d.  r.  Accad.  med.  di  Roma, 
xviii.  p.  231,  1891-2.-149.  Eberlin,  A.  Med.  Obozr.  xxxvii.  p.  1011,  1892.-130. 
Albkrtin.  I^rovinc".  nie'd.  vii.  p.  1.39,  1893.  — 131.  Gelli,  G.  Pratico,  ii.  p.  123,  1892- 
3.  — 1.32.  Doyle,  O.  M.  Journ.  Am.  M.  Assoc  xxi.  p.  773,  1893.- 133.  Buldt,  H.  J. 
Med.  Rec.  xli  v.  p.  790,  1893.  — 134.  Anscheles,  J.  0.  Journ.  akush.  i  jensk.  holiez. 
viii.  p.  7.34,  1893.-1.33.  FAinHEUBE,  A.  Arch,  de  tocol.  p.  212,  1894.  — 136.  Vine- 
berg,  H.  N.  Am.  J.  Obst.  p.  .323,  1893.- 136r(.  Butters,  W.  Diss.  ErlaiiKoii,  1893.— 
ir,()b.  Jacobi,  M.  p.  Am.  J >iirn.  Obst.  xx.xii.  p.  510,  1.S93.  —  1.3(;fr.  Dorland,  W.  A.  N. 
Phila.  Poly.  iv.  p.  483,  18;3.  — 136fL    Olapham,  C.   Quart.  Med.  Journ.  iv.  p.  279,  189(i. 

Uterus  Fcetalis,  Pubescens,  etc. :  — 137.  MOller,  P.  Ztschr./.  Geburtsh.  u.  Gyn. 
iii.  p.  1.39,  1878.  — 158.  Budin.  P.  Progr.  m6d.  pp.  267  and  307,  i.  for  1887.-139. 
Blanc,  E.   Arch,  de  tocol.  p.  339,  1889.  — 160.  Trachet,   Arch,  de  tocol.  xvii.  p.  845, 1890. 

Minor  Malformations  and  Congenital  Prolapsus  Uteri:  — 1(51.  Penrose,  C.  B. 
Univ.  Med.  Mag.  vi.  r>-  183,  189:i-4.  — 162.  Mukm.ek.  Ann.  di  Ostet.  p.  331,  1894.— 
16:'..  (2(iiSLiN(J,  N.  Norsk.  Mag.  /or  Laegevidenskabc'n,  4  R.  iv.  p.  263,  1889.  — 1()4. 
HoKi.ArnKK.  Miini-h.  med.  W^o/ui.s'c/ir.  No.  30,  1889.  — 163.  HiciL,  K.  Arch. /.  Gynuek. 
xlviii.  p.  1.33,  1894.  — 163-t.    Ke.my,  S.     Arch,  de  local,  xxii.  p.  904,  1895. 


MALFORMATIONS   OF   THE    GENITAL    ORGANS  IN    WOMAN     109 

Vagina  Septa :  — lOO.  Suppinger.  Correspondenzhl.  f.  Schiceizer  Aerzte,  p.  418, 
1876.-107.  Atthil,  L.  Dublin  Journ.  Med.  Sc.  Ixiv.  p.  1(>5,  1877.— ltJ8.  Anway, 
J.  D.  Am.  Journ.  Obst.  xi.  p.  388,  1878.- IG'J.  Chekon.  Rev.  med.-chir.  d.  mal.  d. 
femmes,  iv.  p.  382,  1882.  — 170.  Galabin,  A.  L.  Ivans.  Obst.  .'ioc.  London,  xxiv.  p.  20, 
1883.-171.  MouLTON,  H.  Journ.  Am.  Med.  Assoc,  x.  p.  GGO,  1888.-172.  Schuler, 
C.  Diss.  Kiel,  1800.  — 173.  Vasten,  V.  A.  Bolnitsch.  ffaz.  Botkina,  \.  p.  9H6,mjO.— 
174.  Paschen.  Centralbl.f.  Gyniik.  xiv.  p.  lG,mjO.  — 175.  Massey,  G.  B.  Ann.  Gynsec. 
and  Psediat.  iv.  p.  3G5,  1890-1.-170.   Shtol,  K.     Otchet.  Mar.  ginek.  otdiel,  p.  47,  1891. 

—  177.   GuHMAN,  M.    Journ.  Am.  Med.  Assoc,  xvi.  p.  906,  1891.-178.  Cl-ratulo,  G. 

E.  Riforma   med.   vii.  p.  337,  1891.-179.    Ciajo,  A.     Gazz.  d.  osp.  xii.  p.  670,  1891. 

—  180.  SciALDONi,  A.  Gior.  internaz.  d.  sc.  med.  xiii.  p.  5'M,  1891.  — 1S\.  Halter,  G. 
Wien.  med.  Presse,  xxxiii.  p.  49,  1892.-182.  Drujinin,  I.  N.  Journ.  akush.  i  jensk. 
holiez.  vi.  p.  239,  18i)2.  — 18.3.  Giglio,  G.  Riforma  med.  viii.  p.  185,  1892.  — 184. 
SicHERER,  O.  V.  Arch.f.  Gynaek.  xlii.  p.  3.39,  1892.  — 185.  Piccoli,  G.  Levatrlce  mod. 
i.  p.  58,  1892.  — 186.  Eberlin,  A.  Med.  Obozr.  xxxvii.  p.  323,  18;i2.  — 187.  Borde,  L. 
Bull.  d.  sc.7ned.  di  Bologna,  in.  p.  V.n,  1S92.  —  18S.  FUchtenbuch,  H.  Diss.  Stras- 
burg,  1892.-189.  Umamori,  S.  Mino  Igakkwai  Hoko,  No.  1,  p.  86,  1893.  — 190. 
Fermini.  Boll.  d.  Polianibul.  di  Mllano,\\.  p.  hj,189Z.  — 191.  Leuf,  A.  H.  P.  Med. 
News,  Ixiii.  p.  490,  1893.  — 192.  Herrick,  C.  B.  Med.  News,  p.  15,  July  7,  1894.— 
193.  RoBB,  H.  Johns  Hopkins  Hosp.  Bull.  p.  50,  April  1894. —  194.  Semeleder,  F. 
Gaceta  medica  {Me.vico),  p.   287,   1894.-195.   Osmoxt.    Arch.  d.   tocol.  p.   139,  1894. 

—  196.  Chapius.  Lyon  med.  p.  83,  1894.-197.  Ay'ers,  E.  A.  Am.  Journ.  Obst.  p. 
101,  July  1894.  — 1118.  Merttens.  Centralbl.  f.  Gynilk.  xviii.  p.  1001,  1894.-199. 
Raineri,  G.  Ann.  di  Ostet.  p.  473,  1894. — 200.  Schuhl.  Ann.  de  gynec.  p.  248, 
Oct.  1891.  — 201.  Fordyce,  W.  Teratologia,  i.  p.  61,  1894.— 202.  Serejinsky,  G.  P. 
Journ.  akush.  i  jensk.  boliez.  p.  183,  March  1894. — 203.  Eoux,  G.  Arc/i.  de  tocol. 
p.  59,  1895.— 204.   S\yoPE,  S.  D.    Med.  Neios,  p.  391,  April  G,  1895.  — 204a.   Chapmax, 

F.  B.    Boston  Med.  and  Surg.  Journ.  cxxxiii.  p.  622,  1895. 

Vagina  Rudimentaria.  Defectus  Vaginae.  Atresia  Vaginae:  —  205.  Garde,  H.  C. 
Aust7-alas.  Med.  Gaz.  ix.  p.  307,  1889-90.-206.  Picque,  L.  Ann.  d.  gyndc.  xxxiii.  p. 
124,  1890.  —  207.  Saehrendt,  P.  Eln  Beitrag  zu,  den  Missbildungen  der  Vagina  und 
des  Hymen.  Greifswald,  1S90.— 208.  Jacobssohn,  J.  Diss.  St'rasburg,  1890.-209. 
Jacquemard,  G.  Loire  med.  ix.  p.  229,  18".)0.  — 210.  Pascals,  G.  Biforma  med.  y\. 
pt.  1,  1890.  — 211.  Riedinger,  H.     Ztschr.  f.  Ileilk.  xi.  p.  T.il,  1S90.  — 212.   Sokoloff, 

A.  P.  Ann.  d.  gynec.  et  obst.  xxxiii.  p.  47,  1890.  —  213.  Leoxte.  Spitahd,  x.  p.  611, 
1890.-214.  Jepson,  S.  L.  Trans.  M.  Soc.  W.  T7?-.f//«?V(,  p.  759,  1890.  —  215.  Madden. 
T.  M.  Trans.  Roij.  Acad.  Med.  Ireland,  viii.  p.  292,  1890.-216.  Fraxk,  K.  Ztschr. 
f.  Gehurtsh.  u.  Gyn.  xviii.  Hft.  2,  1890.-217.  Asadulla,  M.  Indian  Med.  Gaz.  xxvi. 
"p.  9,  1891.— 218.  RoBB,  H.  Johns  Hopkins  Hosp.  Bidl.  ii.  p.  43,  1891.— 219. 
SwiECiCKi.  THen.  med.  Bl.  xiv.  p.  85,  1891.  —  220.  LoviOT.  Bull,  et  mdm.  soc. 
obst.  et  gyndc.  de  Pa7-is,  p.  78,  1891.  —  221.  Roux.  Cong,  franr.  de  chir.  Proc.-verb.  v. 
p.  497,  "l'891.  — 222.  Delageniere,  H.  Ibid.  p.  .346,  1891.-223.  Vagishita,  T. 
Sei-i-Kwai  Med.  Journ.  x.  p.  170,  1S91. — 224.  Balade.  Journ.  de  med.  de  Bordeaux, 
xxi.  p.  85,  1891-2.  — 225.  Kexnedy,  C.  M.  and  C.  F.  Univ.  M.  Mag.  iv.  p.  703, 
1891-2.— 226.  La  Torre,  F.  Bull.  d.  r.  Accad.  med.  di  Roma,  xviii.  p.  231,  1891-2.— 
227.  Martin,  J.  N.  Am.  Gynsec.  Journ.  ii.  p.  287,  1892.-228.  Fulton,  J.  S.  Am. 
Journ.  Obst.  xxvi.  p.  3.31,  1892.  —  229.  Mangiagalli,  L.  Atti.  d.  Assoc,  med.  Lom- 
barda,i.p.32,  1892.-230.  Plasencia,  I.  Rev.  de  cien.  med.  vii.  p.  169,  1892.-231. 
SwiECiCKi,  H.  de.  Arch,  de  tocol.  et  de  gynec.  xix.  p.  481,  1892.  —  2.32.  Albertix. 
Province  med.  vii.  159,  1893. — 233.    Azema,  H.     Ann.  de  gynec.  xxxix.  p.  214,  1893. 

—  234.  Barker,  F.  C.  Indian  Med.-Chir.  Rn\  i.  p.  140,  ISO:!.- 23"..  Skexe,  A.  J.  C. 
Brooklyn  Med.  Journ.  vii.  p.  63(),  1893.  — 2;:().  Boldt,  H.  J.  Med.  R'c.  xliv.  p.  790, 
1893.  — 237.  Currier,  A.  F.  Neiv  York  Journ.  Gynsec.  and  Obst.  iii.  p.  1086,  1893.-2;^. 
RossA,  E.  Centralbl.  f.  Gyniik.  xviii.  p.  422,  1S94.  — 239.  Costa,  J.  C.  da.  Med. 
News,  p.  269,  Sept.  9,"  1S94.— 240.  Sniox,  M.  Centralbl.  f.  Gyniik.  xviii.  p.  1313, 
1894.— 241.   Graxdix,  E.  H.     Am.  Journ.  Obst.  xx.xi.  p.  249,  1895.-242.   Feixberg, 

B.  Centralbl.  /.  Gyniik.  xix.  p.  395,  1895. — 242«.  Turgard.  Ann.  de  la  Policlin.  de 
Lille,  iv.  p.  177,  1895. — 2-l2b.  Muret.  Wien.  klin.  Rundschau,  ix.  p.  537,  1895. — 
242c.  Hahn,  H.  St.  Louis  Med.  and  Surg.  Journ.  Ixix.  p.  265,  1895.  — 242f/.  Picquk 
and  ViLLAR.  Progr.  med.  p.  284,  Nov.  2,  1895. — 242c.  Picque.  Gaz.  mdd.  de  Paris, 
9.  s.  ii.  p.  522,  1895!— 242/.  "Webster,  J.  C.  Am.  Journ.  Obst.  xxxii.  p.  .'">44,  1895.— 
242(7.  RosSA,  E.     Centralbl.  /.  Gyniik.  xx.  p.  145,  1896. 


SYSTEM   OF  GYNECOLOGY 


Atresia  Vaginae  Lateralis:  — 243.  Wroblewski,  C.  Diss.  Greifswald,  1884.— 
244.  Frae.nkel,  E.  Breslau.  aerztl.  Ztschr.  ix.  p.  G7,  1887.-245.  Sachs,  G.  Med. 
Obozr.  xxxvii.  p.  130,  1892.-241).  Sicherer,  O.  v.  Arch.  f.  Gynaek.  xlii.  p.  339, 
1892.-24:7.  "CuLLiNGWORTH,  C.  J.  Trans.  Am.  Gijn.  Soc.  xviii.  p.  434,  1893.-248. 
Sakger.  Centralbl.  f.  Gijndk.  xviii.  p.  931,  1894.-249.  Muret.  Rev.  med.  de  la 
Suisse  romande,  p.  280,  1893.  —  250.  Karra,  D.  A.  Univ.  izvyestiyu,  xxxv.  p.  149, 
1895. 

Stenosis  Vaginae :  — 251.  Vineberg,  H.  N.  Am.  J.  Ohst.  p.  106,  July  1894.— 
252.   Stone,  A.  K.    Boston  M.  and  S.  Joarn.  ^.5Z'd,l'S^5. 

Abnormal  Communications  of  the  Vagina: — 253.  Garadec.  Gaz.  d.  Hop.  No.  7, 
p.  27,  1863.- 254.  Rosthorn,  A.  v.  Wlen.  klin.  Wchnschr.  No.  10,  p.  183,  1890. — 
255.   FoRDYCE,  W.     Teratologia,  i.  p.  61,  1894. 

Double  Vulva: — 256.  Suppinger.  Correspondenzhl.  f.  Schweizer  Ae7'zte.  p.  418, 
1876.  —  257.  Wells,  B.  H.  A7n.  J.  Obst.  xxi.  p.  1265,  1888.  —  258.  Chiarleoni, 
G.     An7i.  di  Ostet.  e  Ginecologia,  xvi.  p.  469,  1894. 

Atresia  Vulvae  Superficialis : — 259.  Rauschning,  P.  Diss.  Konigsberg,  1890.— 
260.  Sanger.  Centralbl.  f.  Gyniik.  xv.  p.  1022,  1891.— 261.  Vollmer,  H.  Diss. 
Marburg,  1894  (two  cases).  — 261a.  Hue,  F.  i(/ed.  JH/a?i<.  ii.  p.  467,  1895.  — 2616.  Jan, 
M.    Indian  Lancet,  vii.  p.  123,  1896. 

Abnormal  Communications  of  the  Vulva:  —  262.  Elgehausen,  F.  Dissertation. 
Kiel,  1891. 

Anus  Vulvalis: — 263.  Rosthorn,  A.  v.     Wien.  klin.  Wchnschr.  iii.  p.  183,  1890. 

—  264.  Spinelli,  G.  Riv.  din.  e  terap.  xii.  p.  173,  1890.-265.  Abel,  K.  Aj-cU.  f. 
Gynaek.  xxxviii.  p.  493,  1890.-266.  Szukalski,  S.  Diss.  Greilswald,  1890.-267. 
PuECH,  P.  Des  abouchements  congdnitaux  du  rectum  a  la  wive  et  au  vagin.  Paris, 
1890.  —  268.  Frommel,  R.  Miinchen.  med.  Wchnschr.  xxxvii.  p.  264,  1890. — 269. 
HiMMELFARB,  G.  I.  Arch.f.  Gynaek.  xlii.  p.  372,  1892. —270.  Parvin,  T.  Med. 
News,  Ixi.  p.  69,  1892. — 271.  Rautzoin.  Rev.  mens.  d.  nial.  d-'  Venf.  xi.  p.  27,  1893. — 
272.  Thompson,  H.  Lancet,  i.  for  1894,  p.  403. —273.  Horrocks.  Brit.  Med.  Journ. 
i.  for  1895,  p.  83.  —  274.  Buckmaster,  A.  H.  Trans.  Am.  Gyn.  Soc.  xix.  p.  275, 
189i.  — 275.  LuDWiG.  Centralbl./.  GynaJc.  x\x.  p.  349,  1895.-276.  Anshelesa,  U. 
Univ.  izvyestiya,  xxxv.  p.  129,  1895.  —277.  Dwight,  T.  Am.  J.  Med.  So.  p.  433, 
April  1895. — 277a.  Freeman,  L.    il/ed.  A^ews,  Ixvii.  p.  319,  1895. 

Hypospadias:— 278.  Lebedeff.  Arch.  f.  Gynaek.  xvi.  p.  290,  1880.-279. 
Stron<j,  C.  p.  Trans.  Am.  Gyn.  Soc.  xvi.  p.  473,  1891.-280.  Frank.  Wien.  klin. 
Wchnschr.  v.  p.  413,  1892.  —  280a.  Bittner,  C.  Przeglad.  chirurgiczny ,  i.  p.  260, 
1893-4. 

Epispadias: — 281.  Gottschalk,  S.  Dissartation.  Wiirzburg,  1883.  —  282.  Ruther- 
ford, C.  Med.  Re.c.  xxxviii.  p.  492,  1890.  —  283.  Auffret,  G.  Cong.  fran<;.  de  chir. 
Proc.-verb.  etc.  vi.  p.  233,  1892.  —  284.  Dranitzy,  A.  A.  Journ.  akush.  i  jensk.  boliez. 
p.  567,  June  1894.  — 285.  Durand,  M.    L'Exstrophie  vdaicale  et  I'Eiiispndias.    Paris,  1894. 

—  28.5a.  Petren,  K.  Nordiskt.  mnd.  Arkiv,  n.  f.  iv.  No.  31,  1894. — 2856.  Kuster,  E. 
Berlin,  klin.  Wchnschr.  p-  1141,  1895. 

Malformations  of  Labia:— 286.  D'Hotman  de  Villters.  Arch,  de  tocol.  xYn.  p. 
272,  189!).  —  2S7.  Sciitol,  K.  G.  Journ.  ahush.  i  jennk.  holv'z.  iv.  p.  807,  18!)2.— 287a. 
David,  E.  .Journ.  sc.  mdd.  de  Lille,  xviii.  p.  372,  1895.-287^;.  Shoemaker,  G.  E. 
Am.  Journ.  Obst.  xxxii.  p.  215,  1895. 

Atresia  Hymenalis  :  —  288.  Van  der  Meij.  Ned^'l.  Tijdschr.  v.  Verlmk.  en  Gyn.xr. 
i.  p.  171,  ]S8'.).  — 2H9,  Allinson,  H.  C.  Brit.  Med.  Journ.  i.  for  1890,  p.  780.— 290. 
Maker,  J.  J.  E.  Med.  Rcc.  xxxvii.  p.  .WO,  1890.— 291.  Somers,  L.  N.  U.  Lancet,  i.  for 
1890,  p.  1010. —292.  Ckhc:hrz.  Clinicn,  i.  p.  118,  1890.-293.  Sisman,  A.  Wien. 
klin.  Wchnschr.  iii.  p.  4;'.'.),  1890.-294.  Kinloch,  R.  A.  Am.  J.  Ohst.  xxiii.  p.  8.'56, 
1890.-29.'.  Mayer,  O.  P..  Trans.  South  Car.  M.  Ass.  p.  105,  1890.-296.  P.ardescu, 
N.  Sf/ilalul.  X.  p.  3.57,  1890. —297.  Bevill,  C.  Med.  Rec.  xxxviii.  p.  631,  1890.— 
298.   Gichner,  J.   E.     Maryland  M.  Journ.    xxiv.    p.   248,    1890-1.-299.     Wjgcjin, 


MALFORMATIONS  OF   THE    GENITAL    ORGANS  IN   WOMAN     lu 

F.  H.  Med.  Rec.  xxxix.  p.  136,  1891.— 300.  Shtol,  K.  Otchet.  Mar.  ginek.  otdlel,  p. 
28,  1891.  — oOl.  Ross,  J.  F.  W.  Journ.  Am.  M.  Ass.  xvii.  p.  1,  1891.  — 302. 
Hemenway,  H.  B.  Am.  J.  Obst.  xxiv.  p.  897,  1891.-303.  Stuogonoff,  V.  V. 
Vrach,  xii.  p.  1058,  1891.— 30i.  Sochinski,  P.  M.  Vrach,  xii.  p.  1139,  1891.— 
305.  MiRONOFF,  M.  Journ.  akush.  i  jensk.  boliez.  vi.  p.  474,  1892.  —  :!0().  Wheeler, 
A.  Calif.  Homaop.  x.  p.  206,  1892.-307.  Min.\rd,  E.  J.  C.  jH^.  York  M.  Journ.  Ivi.  p. 
299,  1892. —308.  Vanderveer,  J.  R.  N.  York  M.  Journ.  Ivi.  p.  2i)8,  1892.-309. 
KoNELSKi,  M.  L.  Vrach,  xiii.  p.  955,  1892.  —  310.  Orloff,  V.  N.  Medilslna,  iv.  p. 
356,  1892.-311.  Rosinski.  Allg.  med.  Centr.-Ztg.  Ixi.  p.  2041,  1892.-312.  1Jr.\ke- 
Brockman,  H.  E.  Brit.  Med.  Journ.  i.  for  1893,  p.  1220. — 313.  Neugebauek,  ¥. 
L.  Medycyna,  xxi.  p.  429,  1893.-314.  Nammack,  C.  E.  3Ied.  Rec.  xii  v.  p.  81, 
1893.-315.  Thomason,  H.  D.  /bid.  p.  2.35,  1893. —  316.  Kahn,  A.  Med.  News,  Ixiu. 
p.  380,  1893.— 317.  Mudalier,  A.  N.  K.  Indian  Med.  Rec.  p.  300,  1894.  — 318. 
Murphy,  J.  Brit.  Med.  Journ.  i.  for  IS^o,  p.  65. — 318a.  Rittstieg.  Miinchen.  med. 
Wchnschr.  p.  1081,  1895. — 3186.  Coromilas.  Bull,  et  mem.  soc.  obst.  et  gynec.  de 
Paris,  p.  445,  1895. 

Anomalies  in  the  Form  of  the  Hymen:  —  319.  Schaeffer,  O.  Arch.  f.  Gynaek. 
xxxvii.  p.  199,  1890.  —  320.  Cordorelli  Francaviglia,  M.  Gior.  ital.  d.  mal.  ven. 
XXX.  p.  426,  1889.-321.  Montane,  L.  Progreso  mM.  ii.  p.  445,  1890. —322.  Purs- 
low,  C.  E.    Lancet,  i.  for  1895,  p.  543. 

Anomalies  in  the  Structure  of  the  Hymen: — 323.  Leisenring,  P.  S.  Omaha 
C7mic,  ii.  p.  216, 1889-90.— 324.  Destarec.J.  Thesis.  Paris,  1890.  — 325.  Campbell, 
W.  M.  Edin.  M.  Journ.xxxvi.p.2n,mM-l.  — 326.  Ahlfeld,  F.  Ztschr.  f.  Geburtsh. 
u.  Gynak.  xxi.  p.  160,  1891. 

Hermaphroditism:  —  327.  Ballantyne,  J.  W.  Teratologic,  i.  p.  136,  1894.  —  ."28. 
Ibid.     Teratologia,  \\.  p.  184,  1895. — 329.  Debout.    Normandie  med.  v.  p.  160,  1890. 

—  330.  Decker,  C.  M.  St.  Louis  M.  and  S.  Journ.  Iviii.  p.  355,  1890.  —  331.  Egea,  R. 
Gac.  med.  xxv.  p.  141,  1890. — 332.  Rosenthal,  O.  Wien.  med.  Wchnschr.  xl.  p.  526, 
1890.  — 333.  Winter.  Ztschr.  f.  Geburtsh.  u.  Gynlik.  xviii.  p.  359, 1890.  — 334.  Manton. 
J.  A.  Lancet,  n.  for  1890,  p.  395.-335.  Pozzi,  S.  Gaz.  hebd.  de  m^d.  xxvii.  p.  351, 
1800.-336.  Jones,  C.  N.  D.  Med.  Rec.  xxxviii.  p.  724,  1890.-337.  Tillatson,  D. .). 
Med.  and  Surg.  Reporter,  Ixiii.  p.  647,  1890.  —  338.  Abel,  R.  Dissertation.  Greifs- 
wald,  1890.-339.  Vaughan,  G.  T.  Nev)  York  Med.  Journ.  liii.  p.  125,  1891.-340. 
Polaillon.  Bull.  Acad,  de  med.  Paris,  xxv.  p.  557,  1891.  —  341.  Eliot,  G.  T.  Mfd. 
Rec.  xxxix.  p.  564,  1891.-342.  Petit,  P.  N.  Arch,  d'obst.  et  gynec.  vi.  p.  297,  1891.— 
343.  JouiN.  Bull,  et  m&m.  soc.  obst.  et  gynec.  de  Paris,  p.  190,  1891.  —  344.  Debikkhe, 
Ch.    L'Hermuphrodisme.    Paris,  1891.  — 345.   Breitung,  M.    Dissertation.    Jena,  1891. 

—  346.  Roerle,  F.  J.  Trudi  Obsh.  Russk.  vrach  v  Mosk.  p.  17,  1891.-347.  Bishop, 
H.  D.  Med.  Rec.  xii.  p.  321,  1892.-348.  Worrall,  R.  Australas.  M.  Gaz.  xi.  p. 
107,  1891-2.  —349.  Fehling,  H.  Arch.  f.  Gynaek.  xlii.  p.  561,  1892.  — 350.  Messner. 
Arch.  f.  path.  Anat.  cxxix.  p.  203,  1892.  — 351.  Noxne,  M.  Jahrb.  d.  llamb.  Staats- 
krankenansl.  ii.  p.  446,  1892. — 352.  Guermonprez.  line  erreur  de  .spxe  ax'oc  se.t 
consequences,  Lille,  1892. — 353.  Frank.  Prag.  med.  Wchnschr.  xvii.  p.  221,  1892. — 
354.  Richer,  P.  N.iconog.  de  la  Salpctriere,  v.  p.  385,  1892. — 355.  Dailmez,  G. 
Les  sujets  de  sexe  douteux.  Lille  et  Paris,  1892.  —  356.  Lindsay,  J.  Glasgow  Med.  Journ. 
xxxix.  p.  161,  1893.  — .357.  KuRZ,  A.  Deutsche  med.  Wchnschr.  xix.  p.  964,  1893.— 
358.  Philippe,  P.  Union  mtid.  du  Canada,  yn.  p.  505,  lS9'3.—3,'^9.  Audain,  L.  Ann. 
de  gynec.  et  d'obst.  xl.  p.  3()2,  1893.  —  360.   Bergonzoli,  G.     Bull,  scient.  No.  1,  1893. 

—  361.  Pozzi,  S.  A  Treatise  on  Gynecology,  iii.  p.  452,  1893.  — 362.  Brohl.  Cen- 
tralbl.  f.  Gynclk.  xviii.  p.  390,  1894.-363.  Hoffmann,  0.  S.  Am.  J.  Obst.  xxix.  p. 
367,  1894.-364.  Martin,  C.  Brit.  Med.  Journ.  i.  for  1894,  p.  1361.  — 3r>5.  Walker, 
M.  A.  New  York  Med.  Journ.  p.  434,  Oft.  1894.  —  366.  Zuccarelli,  A.  L'Anonialo, 
p.  78,  1894.  — 3(;7.  Willett.  Trans.  Path.  Soc.  London,  xlv.  p.  102,  ISiU.- ."6.*<. 
Moostakov.  Meditzina  (5«/r/om(),  p.  32,  1894.  —  .369.  Schneller.  Mimchen.  m<\i. 
Wchnschr.  No.  33,  1894.-370.  Hallopeau,  H.  Bull.  Acad,  de  mf<d.  Paris,  p.  425. 
1895. —  ;>71.  Lagneau,  G.  Ibid.  p.  415,  1S95.  —  .372.  Meige,  H.  N.  iconogr.  de  In 
Salpctriere,  p.  .56,  1895.-373.  Pean.  Bull.  Acad,  de  m4d.  Paris,  p.  381.  1895.  — .■?74. 
Tar(}ett,  J.  H.  Trans.  Ohst.  Soc.  London,  xxxvi.  p.  272,  1895.— 375.  Zedel,  J. 
Ztschr.  f.  Geburtsh.  u.  Gyniik.  xxxii.  p.  230,  1895.  —  375a.  Lifka,  A.  Gaz.  Ickarska, 
XV.  p.  980,  1895.— 375&.   Bittner,  W.     Prag.  med.  Wchn.^chr.  xx.  p.  491,  1895. —375c. 


H2  SYSTEiM  OF  GYNECOLOGY 

MiKOT,  F.  Boston  Med.  and  Surg.  Journ.  cxxxiii.  p.  112,  1895. — 375(7.  Stretton, 
J.  L.  io«ce?,  p.  917,  ii.  for  1895.— 375e.  Neugebauee,  F.  Przeglad  chirurgiczny,  n. 
pp.  82,  539,  ,1894-5.-375/.  Kaplan,  P.  S.  Diss.  Berlin,  1895.  — 375(7.  Blom,  R. 
Centralbl.  f.  Gyniik.  xix.  p.  685,  1895.  — 375/i.  Arene.  Loire  mid.  xiv.  p.  187,  1895. — 
375t.  Hutchinson,  J.    Arch.  Surg.  vii.  p.  64,  1896. 

J.  W.  B. 


THE  ETIOLOGY  OF  THE   DISEASES   OF  THE  FEMALE 
GENITAL   ORGANS 

The  causes  of  the  diseases  of  modern  Avomen  are  mainly  attributable  to 
the  errors,  direct  or  indirect,  of  modern  life,  which  is  yet  very  far  from 
perfection.     They  may  be  thus  classed  — 

I.  Abnormalities,  which  are  produced  by 

A.  Hereditary  congenital  deficiencies  of  development,  with 

(a)   Reversion  to  an  anterior  biological  type ;  or 
(j8)   Imperfection  of  adjustment,  or  of  function,  of  certain 
structures ; 

B.  Congenital,  or  subsequent  arrests  of  development  by  bacillary 

inflammation  or  accident ;  and 

C.  Constitutional  defect,  in  which  certain  classes  of  cells  mor- 

bidly proliferate,  forming  tumours. 

II.  The  training  and  effects  of  education. 

III.  Unnatural  personal  habits  with  regard  to  dress,  diet,  repose, 
and  the  management  of  the  excretions. 

IV.  Absence  of  marriage,  or  late  or  ineffective  marriage ;  the  last 
including  al>sence  of  pregnancy  by  congenital  defect  or  incapacity  of  the 
husVjand,  or  of  the  woman ;  and  artificial  prevention  of  pregnancy. 

V.  Excessive  use  and  drain  of  the  sexual  organs. 

VI.  Bacillary  contagious  diseases,  such  as  syphilis,  gonorrhcsa,  puerpe- 
ral septicaemia,  tuberculosis,  measles,  scarlatina,  small-pox,  and  diphtheria. 

VII.  Accidental  causes  and  those  due  to  operation. 

I.  Deficiencies  and  arrests  of  development,  which  render  the  gen- 
ital organs  useless  or  lead  to  disease,  might  be  attributed  to  inflam- 
matory interference  with  the  circulation  and  nutrition  due  to  maternal 
endometritis,  or  mental  shock;  but  these  influence  the  whole  embryo,  or 
not  especially  its  genital  system.  The  cause  is  rather  to  be  found  in  the 
influences  of  hereditary  sexual  feebleness,  progressive  in  certain  temper- 
aments ;  or  of  bacillary  inflammation ;  or  of  local  injury  in  the  mother. 

A.  Such  defective  heredity  is  probably  not  generally  immediate, 
but  is  a  gradual  declension,  generally  on  the  maternal  side,  tending  by 
continuous  degeneration  to  induce  in  the  progeny  feeble  sexual  foi'ma- 
tion,  frequently  in  the  uterus.  Thus  the  first  stage  may  be  found  in  a 
woman  of  deficient  sexual  appetite,  having  a  uterus  of  moderate  dev(ilop- 
ment,  but  contracted  at  its  opening,  wli  ic.li  may  Ije  lacerated  in  her  first  con- 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL   ORGANS     113 

finement  so,  perhaps,  as  to  prevent  further  conception.  The  child,  cohl- 
mannered,  unsympathetic  and  egoistic,  with  a  feebly  developed  uterus  and 
disgust  at  marital  rites,  becomes  pregnant  only  by  chance  —  it  may  be 
long  after  marriage,  or  after  successful  operation  :  or,  with  a  congenitally 
contracted,  though  permeable  upper  vagina,  closed  hymen,  or  a  tendency 
to  the  infantile  pelvis  with  absence  of  sexual  appetite,  she  becomes  the 
mother  of  one  child,  who  has  a  j^et  feebler  unimpregnable  uterus  and 
atrophic  ovaries,  with  deficient  catamenial  discharge,  and  a  premature 
menopause ;  or  more  marked  abnormality  may  occur,  and  the  woman  be 
sterile.  In  the  father  hypospadias  may  exist,  or  some  other  state  of  de- 
ficient congenital  urogenital  formation.  Such  unions  are  often  attribu- 
table to  the  inducements  of  money  or  position  in  marriage;  in  a  simpler 
state  of  society  they  would  be  prevented  by  the  competitive  success  of 
those  physically  more  robust.  This  heredity  may  be  rectified  in  the  chil- 
dren if  the  feebly  sexual  woman  become  pregnant  by  a  partner  of  excep- 
tionally vigorous  type,  whereby  the  tendency  to  sexual  deterioration  may 
be  neutralised. 

Through  the  ancestral  series  a  certain  portion  of  the  original  germ- 
plasma  has  been  retained,  so  that  the  special  organisation  is  preserved,  as 
well  as  some  particular  attributes,  whether  physical  or  mental,  of  the  par- 
ents or  earlier  progenitors.  The  influence  of  the  highest  progressive  de- 
velopment attained  is  thus  conveyed  to  the  offspring,  but  with  it  the 
inherent  capacity  of  recurrence  to  an  anterior  lower  type.  A  defective 
generative  vitality  may  thus  fail  to  develop  to  the  highest  type  of  the 
immediate  ancestors,  and  reversion  to  an  anterior  form  may  occur. 

As  in  all  cases  the  special  type  of  the  individual  is  dominant,  the 
impression  of  descent  is  one  of  degree,  and  the  grade  is  in  a  proportion- 
ately decreasing  ratio  removed  from  that  of  the  immediate  ancestors ; 
and  this  appears  in  some  special  point,  in  which  the  advanced  cell-vitality 
has  failed.  This  is  particularly  liable  to  occur  in  the  generative  organs, 
especially  of  women,  which  are  more  advanced  and  complicated. 

Darwin  says  that  the  most  ancient  progenitors  of  the  Yertebrata, 
of  which  we  are  able  to  obtain  an  obscure  glance,  seem  to  have  been 
a  group  of  marine  animals  resembling  the  larvae  of  existing  ascidians. 
These  animals  probably  gave  rise  to  a  group  of  fishes,  as  lowly  organised 
as  the  lancelot;  and  from  these  the  ganoids,  and  other  fishes  like  the 
lepidosiren,  were  probably  developed.  From  such  fish  a  very  small  ad- 
vance would  carry  us  on  to  the  amphibians.  Birds  and  reptiles  were 
once  intimately  connected  together,  and  the  monotremata  now  connect 
mammals  with  reptiles  in  a  slight  degree.  In  the  class  of  mammals 
the  ancient  monotremata  led  up  to  the  ancient  marsupials,  and  these  to  the 
early  progenitors  of  the  placental  mammals.  Thus  we  may  ascend  to  the 
lemuridaj,  and  from  these  the  interval  to  the  simiadie  is  not  very  wide. 
The  simiad;ii  then  branched  off  into  two  great  stems,  the  New  World  antl 
Old  World  monkeys  ;  and  out  of  the  latter  stem,  at  some  remote  period, 
man,  the  wonder  and  glory  of  the  universe,  proceeded. 

Geddes    and    Thomson   state  that  in  all   the  lower  vertebrata  the 


114 


SVST£A/   OF  GYNyECOLOGY 


two  oviducts  are  distinct  throughout  the  genital  canal ;  but  in  mammals 
the  division  is  found  only  in  the  monotremata.    In  marsupials  the  vagina 

is  single,  but  the  uterus  double ;  and 
in  most  placentalia  theupper  portion 
of  the  uterus  is  double. 

Gegenbaur  describes  the  progress 
in  development  in  the  marsupialia 
in  which  the  two  uteri  are  distinct, 
and  two  separate  vaginae  appear 
(Fig.  40),  and  says  that  in  many  ro- 
dents (lagostomus)  a  certain  portion 
of  the  vagina  retains  its  original 
double  nature.  The  gradual  bio- 
logical progress  toward  the  human 
double  uterus  is  sho^yn  in  Figs.  41, 
42,  43,  in  which  it  is  also  seen  that 
when  the  common  portion  of  the 
uterus  is  elongated  the  cornua  are 
shortened.  In  the  simiadse,  as  in 
man,  there  is  a  single  uterus. 

The  same  line  of  proof  may  be 
applied  to  lobate  and  multiple  ova- 
ries, and  to  the  various   conditions 
of    hermaphrodites.     Thus   heredi- 
tary deficiencies  of  development  are  reversions  to  an  anterior  type. 

These  abnormalities,  however,  are  more  particularly  attributable  to 
the  exact  point  at  which  the  progressive  development  of  the  germinal 


Fiii.  40.  —  Female  generative  organs  of  Halmaturus 
(Gegenbaur).  ov.  Ovary ;  od,  oviduct ;  u, 
uterus  ;  cv,  vaginal  canals  ;  cug,  sinus  uro- 
genitalis  ;  ^■M,  urinary  bladder  ;  Mr,  ureter. 
*  Opening  of  the  bladder. 


Yui.  41.  —  Two  completely  separated 
uteri  of  many  Kodentia. 


Fio.  42.  —  The  single  uterus  Is 
continued  into  two  separate 
cornua  of  the  Insectivora, 
Carnivora,  Cetacea,  and  Un- 
gulata. 


Fig.  43.  ■ 


-The  single  uterus  of  the 
Bimite  and  Man. 


Various  forms  of  the  uterus  (Gegenbaur).     u.  Uterus  ;  od,  oviduct ;  v,  vagina. 

cells  fails.  Pure  reversion  to  an  anterior  type  implies  a  perfect  develop- 
ment at  the  level  of  that  ancestor;  this,  however,  may  not  occur. 
Probably  no  defective  development  can  take  place  without  a  deficient 
germinal  cell-vitality,  and  such  vitality  may  be  exhausted  at  a  point 
antecedent  to  that  of  completion  of  the  anterior  type.  Thus  examples 
may  be  found  in  wliicli  tlio  condition  may  bo  described  as  deficient  in 


ETIOLOGY   OF  DISEASES    OF  FEMALE    GENITAL    ORGANS     115 

contrast  with  that  of  arrest.  In  the  former  the  cell  vitality  is  low,  but 
persistent ;  in  the  latter  it  is  worn  out  and  atrophic. 

B.  And  here  presents  itself  a  special  cause  of  germinal-cell  destruc- 
tion by  bacillary  action,  which  is,  through  parental  influence,  directly 
conveyed  to  the  embryo,  and  by  local  inflammation  destroys  the  vitality 
and  power  of  growth  of  germinal  genital  cells.  Among  such  causes  are 
the  eruptive  fevers,  such  as  measles,  scarlet  fever,  and  small-pox,  by 
which  the  foetus  in  utero  may  be  attacked.  Syphilis  probably  also 
exerts  a  determining  influence  on  arrests  of  development  in  the  progeny. 

After  birth,  and  at  any  time  previous  to  full  development,  these 
causes,  or  tuberculosis  again,  which  specially  attacks  the  mucous  or  serous 
membranes,  may  affect  and  destroy  the  vitality  of  the  growing  cells ;  or 
an  accident  before  birth,  or  subsequently,  such  as  a  blow  on  the  abdomen 
producing  an  internal  haemorrhage,  peritoneal  or  otherwise,  and  affecting 
these  parts,  may  arrest  groAvth  ;  or  a  peritonitis  may  cause  displacement 
and  adhesion  of  the  genital  organs. 

Such  destruction  of  vital  force  in  the  special  germ-cells  produces 
arrest  of  development  at  the  stage  Avhich  such  development  had  pre- 
viously attained,  and  a  stage  of  arrest  restricted  to  the  special  cells 
thus  affected. 

There  is  no  necessary  relation  between  any  degree  of  defect  or  arrest 
in  the  development  of  the  pelvic  sexual  organs  and  the  degrees  of  per- 
fection of  female  form  and  of  the  rest  of  the  woman. 

Congenital  deficiencies  and  arrests  of  development  are  found  in  the 
ovaries.  Fallopian  tubes,  uterus,  vagina,  hymen,  and  vulva. 

Should  the  development  of  the  genital  ridge  be  deficient  or  arrested 
the  ovaries  are  so  undeveloped  that  the  external  germinal  epithelium  has 
not  ingrown  for  the  formation  of  the  Graafian  follicles ;  or  is  so  wanting  in 
completeness  of  structure,  that  these  organs  are  unable  to  arrive  at  their 
successive  monthly  maturity.     Whence  result  amenorrhoea  and  sterility. 

If  the  growth  of  the  cephalad  part  of  the  Miillerian  ducts,  and  of  the 
mesenchyma  of  the  urogenital  fold  cease,  the  Fallopian  tubes  are  minute 
or  defective.  By  absence  of  fusion  of  the  cephalad  ends. of  the  two 
Miillerian  ducts  in  the  genital  cord,  which  are  always  tubular,  the  uterus 
is  double ;  by  absence  of  fusion  of  the  upper  ends  of  the  cephalad  end, 
and  its  presence  in  the  lower  part,  the  uterus  is  bifid  ;  from  arrest  in  one 
duct  and  development  of  the  other,  the  unicorn  uterus  results ;  after  the 
normal  fusion,  cessation  of  vital  growth  may  cause  the  uterus  to  be 
diminutive. 

When  the  vital  force  is  defective  or  arrested  in  the  lower  half  of  the 
genital  cord,  so  that  fusion  and  absorption  of  the  internal  Avails  of  the 
two  Miillerian  ducts  do  not  occur  but  the  remaining  development  con- 
tinues in  each,  the  epithelial  surfaces  of  each  may  separately  continue 
their  growth,  meet  and  coalesce,  closing  the  canals,  and  forming  the 
])roliferating  cellular  lamina  ;  the  central  duct-cells  may  subsequently 
li(]uefy  normally,  and  residt  in  two  vaginae  of  more  or  less  perfect 
formation.     When  the  central  cells  of  the  ducts  have  failed  to  break 


ii6  SYSTEM   OF  GYN.-ECOLOGY 

down,  no  vaginal  canal  is  formed ;  or  the  cells  of  one  may  have  liquefied, 
when  one  vagina,  perhaps  of  defective  size,  is  present.  Such  cohesion 
of  the  vaginal  walls  may  be  maintained  only  by  a  thin,  delicate,  easily 
separated  layer  of  the  central  epithelial  cells,  liquefaction  of  the  central 
lamina  having  just  failed  of  completion. 

The  hymen,  a  non-muscular  fold  which  projects  into  the  urogenital 
sinus,  having  on  the  outer  surface  the  epithelium  of  the  sinus  and  on  the 
inner  that  of  the  vagina,  may  be  imperforate  by  arrest  of  liquefaction  of 
the  lowest  cells  of  the  vaginal  lamina,  and  non-formation  of  a  canal ;  or 
may  have  an  opening  into  each  canal  of  a  double  vagina  by  absence  of 
fusion  of  the  lower  ends  of  the  Milllerian  ducts  ;  or  have  two  openings 
into  a  single  vagina  by  non-fusion  of  the  lowest  ]\lullerian  duct-walls, 
with  liquefaction  of  the  central  epithelial  cells  of  each. 

Deficient  formation  of  the  clitoris  and  nymphae  is  due  to  defect  or 
arrest  of  development  of  the  genital  tubercle;  and  of  the  labia  majora, 
of  the  mesodermic  prominences  on  either  side  of  the  genital  tubercle. 

The  diseases  which  result  from  defect  or  arrest  of  development  in 
atresia  with  ovaries  so  well  formed  that  the  catamenia  occur,  depend  upon 
distension  of  the  genital  canal,  which  is  patent  above  the  occluded 
portion,  by  the  collection  of  the  retained  menses.  Thus,  with  a  closed 
hymen,  or  atresic  vagina,  the  menses  may  dilate  the  vagina,  collect  in 
the  uterus,  and  fill  and  distend  the  tubes  up  to  the  fimbria?.  Should 
effusion  of  the  menses  occur  through  the  fimbrise  into  the  peritoneum, 
peritonitis  results,  of  a  degree  of  mildness  or  severity  proportionate  to 
the  quantity  and  quality  of  the  fluid  effused  if  it  occur  before  operation 
for  the  cure  of  the  atresia ;  it  will  probably  be  septic  and  virulent  if  it 
occur  after  it. 

Each  segment  of  the  double  uterus  may  contain  an  impregnated 
ovum,  the  two  perhaps  of  different  ages ;  and  thus  superfoetation  may 
be  simulated. 

The  usually  more  feeble  structure  of  an  unicorn  uterus,  or  of  a 
segment  of  a  bifid  uterus,  occupied  by  an  impregnated  ovum  in  progress 
of  development,  may  cause  its  rupture  into  the  abdominal  cavity,  and 
thus  produce  abdominal  hematocele  and  peritonitis. 

Supernumerary  developments,  as  of  nipples,  are  multiplications  due 
to  recurrence  to  an  anterior  type;  or  to  embryonic  separation  or  migration 
of  the  special  epidermal  cells;  and  duplication,  as  of  ovaries,  is  attribu- 
table to  embryonic  cleavage.  Duplication  of  the  ovaries,  if  overlooked 
in  oophorectomy  for  the  production  of  the  menopause,  may  defeat  the 
object  of  the  operation. 

The  deficiency  or  absence  of  sexual  appetite,  and  thus  of  engorgement 
of  the  erectile  structures,  is  attributable  to  defective  nerve  formation  in 
the  vaginal  plexus  of  the  pelvic  or  inferior  hypogastric  plexus,  and  tends 
to  feebler  development  of  progeny  from  diminished  size  of  tlie  supplying 
vessels.  This  is  the  most  common  deficiency  of  development  in  these 
organs  in  civilised  people :  it  is  frequently,  thougli  not  necessarily,  associ- 
ated with  the  presence  of  a  congenitally  feeble  uterus  ;  and  also,  but  less 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     117 

commonly,  with  a  uterus  Avhich  is  normal,  except  that  there  is  deficiency 
in  size  of  the  external  opening :  all  these  things  tend  towards  sterility  or 
limitation  of  propagation,  either  by  direct  prevention  of  the  entrance 
of  the  sperm,  or  by  that  frequent  refusal  of  intercourse,  and  subsequent 
avoidance  by  the  husband,  which  is  commonly  known  as  incompatibility 
of  temper. 

The  uterus,  with  normal  length  of  cavity  but  of  feeble  development, 
may  be  deficient  in  size,  strength,  and  weight ;  and  may  have  a  feeble  cer- 
vico-corporeal  junction,  so  that  the  body,  unable  to  maintain  its  normally 
slightly  anterior  curvature,  may  fall  by  the  pressure  of  the  intestines  above 
it  into  the  horizontal  position ;  the  cervix,  on  the  other  hand,  readily 
yielding  to  the  anterior  force  of  a  distended  rectum,  looks  forwards 
and  downwards ;  thus  the  anteflexion  of  the  feebly  developed  uterus 
ensues.  With  this  in  the  marked  condition,  is  coincident  deficiency  in 
size  of  the  opening,  so  that  obstruction — by  the  angle  of  the  anteflexion 
—  to  the  passage  of  the  secretions  increases  the  tendenc}'  to  their  delay 
within  the  cavity  of  the  uterine  body :  the  latter  is  thereby  the  more 
strongly  depressed  into  the  horizontal  position,  and  dysmenorrhoea  and 
sterility  result. 

The  cervicitis  occasionally  found  in  connection  Avith  the  feeble  ante- 
flexed  uterus  is  thus  produced.  The  secretions  collect  within  the  cavity 
of  the  body  by  the  obstruction  at  the  inner  os,  which  is  usually  caused 
by  the  angle  of  flexion ;  distension  then  induces  muscular  contraction, 
and  this  forces  the  menstrual  blood  past  the  angle  into  the  cervical  canal ; 
but  as  the  external  opening  is  congenitally  minute,  escape  is  again  hin- 
dered, and  the  cervical  cavity  is  thus  also  dilated  :  the  quantity  of  the 
corporeal  secretion  increases,  muscular  contraction  follows,  and  escape 
is  effected;  but  the  cervical  membrane  at  the  external  os  has  been 
depressed,  irritated,  inflamed,  thickened,  everted,  and  become  granular, 
and  this,  however  slight  it  may  be,  narrows  the  opening  yet  farther.  The 
cervical  tubulo-racemose  glands  have  been  compressed  by  the  pressure 
of  the  secretions,  and  their  mucus  is  thus  retained  within  their  tubules ; 
they  become  irritated  and  inflamed,  and  secrete  an  increased  quantity 
of  mucus,  which  becomes  abnormally  cohesive  and  ropy.  This  mucus 
presently  extends  from  the  columnar  secreting  cells  in  the  glands,  occupies 
their  canals,  unites  with  the  secretion  of  adjacent  glands,  fills  the  cervix, 
projects  through  the  external  os,  and  by  its  constant  pressure  gradually 
dilates  the  external  os.  Thus  at  the  time  of  examination  the  cervix  may 
present  downwards  and  forwards,  the  external  opening  may  be  of  normal 
size  and  occupied  by  cervical  mucus,  the  cervical  canal  may  be  dilated, 
the  inner  os,  perhaps  lying  to  the  side  of  the  central  line  from  unequal 
lateral  hyperplasia,  may  be  diflicult  to  find:  the  body  of  the  uterus 
may  be  horizontal,  forming  an  acute  angle  of  anteflexion  with  the  cervix, 
and  the  whole  uterus  may  be  of  feeble  structural  development,  although 
it  may  measure  2^  inches  in  its  canal.  The  dysmenorrhoea  may  have 
ceased  or  not,  according  to  the  degree  of  stenosis,  by  bending  or  hyper- 
plasia of  the  inner  os  ;  but  sterility  remains. 


iiS  SYSTEM  OF  GYNECOLOGY 

The  dysmenorrhoea  which  occurs  a  day  or  so  before  the  flow  is  due  to 
engorged  vessels  in  the  endometrium  around  the  utricular  glands  ana  on 
the  mucous  membrane,  of  which  the  columnar  epithelial  cells  and  under- 
lying connective-tissue-matrix  are  proliferated ;  so  that  the  general  struct- 
ure is  thickened,  and  presses  on  the  irritable  nerves  derived  from  the 
pelvic  plexus  — the  pain  being  referred  to  the  promontory  of  the  sacrum, 
and  ceasing  when  escape  of  blood  from  the  vessels  relieves  their  tension. 
But  the  dysmenorrhoea  occurring  synchronously  with  the  flow,  in  conse- 
quence of  rapid  uterine  distension  and  contraction  necessary  to  overcome 
obstruction,  is  felt  at  the  lower  abdomen  in  the  uterus  itself ;  and  this 
ceases  when  the  stenosis  has  been  overcome  and  continuous  escape  estab- 
lished. 

The  normal  uterus  may  be  deficient  only  in  the  form  of  the  conical 
cervix,  or  in  the  size  of  the  external  opening — due,  in  the  former  case, 
to  deficient  cervical  structural  development,  and,  in  both,  as  to  size  of 
the  opening,  to  deficiency  of  development  of  the  lower  part  of  the  cervical 
canal,  or  to  undue  contraction  of  the  lower  circular  muscular  fibres. 
The  body  may  be  weighed  down  by  temporary  catamenial  retention  or 
excessive  abdominal  pressure,  and  thus  be  horizontal,  occasioning  some 
stenosis  by  bending  at  the  upper  cervix  :  generally  speaking,  dysmenor- 
rhoea and  sterility  will  ensue. 

Again,  the  uterus  may  be  well  and  strongly  developed  in  all  other 
respects,  but  the  cervical  mucous  membrane  at  the  external  orifice,  which 
often  extends  on  to  the  vaginal  face  of  the  cervix,  may  extend  within  the 
cervical  cavity.  The  simple  early  embryonic  epithelium,  lining  the  cavity 
of  the  genital  canal  during  development,  changes  its  character  in  the  lower 
third,  which  is  the  vaginal  portion,  becoming  there  a  stratified  pavement 
epithelium,  which  passes  very  gradually  into  the  cylindrical  epithelium 
of  the  upper,  uterine  portion.  The  change  progresses  upward,  and,  as  it 
advances,  the  demarcation  between  the  two  kinds  of  epithelium  becomes 
sharper,  and  at  the  eighth  month  of  utero-gestation  is  abrupt  at  the 
junction  of  the  uterine  with  the  vaginal  canal ;  the  vaginal  stratified 
epithelium  often  extends  a  short  distance  inside  the  os  uteri  (Minot),  but, 
on  the  other  hand,  frequently  fails  to  reach  it.  This  congenital,  ap- 
parently granular  os  is  attributable  to  one  or  other  of  the  following 
conditions  :  — 

(1)  That  the  vaginal  stratified  epithelium  is  deficient  in  extent  of 
growth  up  to  the  lower  border  of  the  cervical  canal,  and  thus  the  cylin- 
drical epithelium  jtrojects  into  the  vagina,  and  is  exposed ;  or 

(2j  That  the  lower  cervical  glands  and  cylindrical  epithelium,  being 
developed  beyond  the  enclosed  lower  cervical  opening,  remain  exposed, 
because  the  circular  muscular  fibres,  which  become  distinct  about  the  close 
of  the  fifth  month,  do  not  subsequently  contract  at  the  lower  border  of 
the  cervical  canal  sufficiently  to  include  them  within  the  canal. 

The  effect  of  this  exposure  of  the  glandular  structures  at  the  external 
opening  of  the  cei'vix  to  the  influences  of  the  acid  vaginal  secretions,  and 
to  friction  against  the  vagina  on  movement,  intensified  by  fixation  due  to 


ETIOLOGY   OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     119 

abnormal  abdominal  pressure,  is  the  production  of  an  excessive  supply 
of  blood,  which  causes  congestion  and  inflammation  of  the  glands  and 
increased  secretion  of  their  strongly  cohesive  mucus,  Avhich  plugs  the 
canal :  the  uterine  vessels  thus  becoming  enlarged,  a  varicose  state  may 
be  induced,  and  the  whole  uterus  become  congested,  so  that  general 
endometritis  ensues.  Also,  the  connective  tissue  at  the  face  of  the  cervix 
becomes  hyperplastic,  the  lips  are  compressed,  and  thereby  the  secretions, 
which  are  usually  plentiful,  rind  difficulty  in  escape  :  the  uterus  becomes 
irritated  by  distension,  so  that  endometritis  is  increased,  and  evolution- 
ary disease  of  the  tubes,  peritoneum,  and  ovaries,  and  (under  the  con- 
current influence  of  excessive  abdominal  pressure)  anteflexion  or  retro- 
version ensue :  hence  result  virginal  menorrhagia  and  dy  smenorrhcea,  and 
sterility  on  marriage. 

Vigorous  sexual  development  is  specially  noticeable  in  families  and 
races  which  bear  many  children,  among  which  may  be  particularly  men- 
tioned nations  inhabiting  or  derived  from  the  warmer  climates.  Of  these, 
Jewesses  are  liable  to  the  congenital  granular  os  of  strong  formation, 
and  to  the  small  external  opening.  These  conditions  are  compatible 
with  coincidence  of  such  a  deficiency  of  development  as  permits  the 
closure,  or  almost  complete  closure,  of  the  genital  canal  by  the  hymen. 

The  deficient  structure  of  the  cervix  of  the  feeble  antefiexed  uterus, 
through  the  small  opening  of  which  the  sperm  has  by  chance  passed 
and  impregnated  the  ovum,  is,  even  on  the  hypernutrition  of  pregnancy, 
ill  adapted  to  bear  the  strain  of  dilatation  in  labour.  The  pressure  of 
the  membranes  does  not  act  to  advantage  on  the  minute  opening,  so 
that  the  cervix  may  be  stretched  out  and  rigid,  and  the  wedge  of  the 
membranes  unable  to  engage.  Thus  the  circular  fibres  are  irritated,  are 
in  a  state  of  tonic  spasm,  and  act  at  advantage ;  but  the  longitudinal 
fibres,  being  lengthened  by  the  downward  pressure  of  the  rounded 
membranes,  act  at  disadvantage.  Shoidd  the  expulsive  force  be  suffi- 
cient and  the  spasm  continue,  laceration  of  the  cervix  may  be  very  ex- 
tensive ;  or  the  lower  segment  of  the  uterus  may  rupture  or  be  torn  off. 

On  dilatation,  the  circular  muscular  fibres  are  deficient  in  strength 
and  the  cervix  in  structural  breadth ;  thxis  laceration  is  frequent. 

In  the  strong  uterus  with  a  deficiently  developed  os,  there  is  a 
liability  to  laceration  from  the  comparative  non-dilatability  of  the 
small  opening.  Should  bilateral  laceration  occur,  lateral  eversion  takes 
place  from  contraction  of  the  two  halves  of  the  torn  circular  musciilar 
fibres ;  and  horizontal  eversion  of  the  cervical  face  from  contraction 
of  the  longitudinal  muscular  fibres,  which  are  no  longer  restrained  by 
the  circular.  But  the  edges  of  the  wound  are  healthy,  and  the  epithe- 
lium may  readily  spread  thence  on  to  the  raw  surfaces,  iniless  pre- 
vented by  subsequent  vaginal  friction  from  undue  abdominal  pressure. 

In  unilateral  laceration  eversion  is  apt  to  be  slight;  the  circular 
fibres  are  ruptured  at  one  side  only,  and  the  other  side  remains  of 
strong  structure,  sufficient  to  counteract  the  longitudinal  contraction 
and  prevent  eversion  of  the  face  of  the  cervix ;  the  circular  fibres,  on 


SYSTEM   OF  GYNECOLOGY 


the  other  hand,  having  only  one  line  of  laceration,  retract  at  slight 
advantage.     Thus  the  eversion  is  only  unilateral,  and  of  small  extent. 

These  actions,  necessarily  less  marked  in  the  feeble  cervix  because 
it  is  small  in  every  direction,  are  accentuated  in  the  large,  strongly 
developed  cervix. 

To  pressure  in  labour,  long  continued  by  the  difficulty  of  dilatation 
of  the  small  opening  or  other  conditions  of  obstruction,  may  be  due,  by 
stasis  of  blood,  the  necrosis  of  tissue  which,  on  separation  after  a  few  days, 
permits  the  passage  of  the  excretions  of  the  adjacent  bladder  or  rectum 
affected,  as  well  as  of  the  slough,  through  the  genital  canal.  Thereby 
a  sinus  is  formed,  called  vesico-vaginal,  recto-vaginal,  or  other  fistula. 

In  pregnancy  in  the  strong  uterus,  with  the  virginal  everted  granular 
face  and  hyperplasia,  from  the  large  size  of  the  opening  dilatation  pro- 
ceeds readily  up  to  a  certain  point,  when  the  head  commences  to  pass. 
But  the  connective  hyperplasia  is  ill  adapted  to  excessive  dilatation ; 
and,  when  the  great  strain  of  expulsion  of  the  head  through  the  cervix 
is  put  upon  it  by  the  well-developed  uterus,  extensive  laceration  of  the 
cervix  usually  results.  The  subsequent  granular  face  and  eversion  are 
apt  to  be  great ;  for  the  previously  granular  hyperplastic  membrane  is 
not  readily  susceptible  to  epithelial  growth,  and  the  raw  and  deeper 
newly  lacerated  central  faces  are  thus  far  removed,  except  at  the  sides, 
from  vaginal  epithelium.  Moreover,  the  longitudinal  cervical  muscular 
fibres  act  at  advantage,  so  that  the  lower  edges  of  the  faces  are  drawn 
upwards  and  outwards,  and  everted.  This  action  is  not  restrained  by 
the  circular  fibres,  which  are  torn  across ;  hence  the  lateral  edges  of 
the  cervical  wound  are  drawn  outwards,  and  still  more  everted. 

In  subsequent  confinements  the  extent  of  laceration  is  generally 
increased,  since  the  angles  of  previous  laceration  are  healed  by  cicatri- 
cial connective  tissue,  which  is  ill  adapted  for  dilatation ;  or  they  may 
also  be  hyperplastic,  which  is  still  less  so,  being  softer  and  less  strongly 
formed  and  resistant. 

When  the  first  stage  of  labour  has  been  unduly  prolonged  by  delay 
in  dilatation  of  the  strong  cervix  with  deficient  formation  of  the  os,  the 
uterus  is  liable  to  become  irritable,  and  to  be  aroused  to  excessive  vigour 
of  contraction,  in  which,  owing  to  the  pain  and  general  excitability  of  the 
woman,  the  accessory  muscles  participate;  thus  labour  is  precipitated  and 
the  head  may  be  forced  down  with  violence  on  the  perineum.  Should 
the  power  be  much  greater  than  the  resistance,  the  head  may  burst 
through  the  perineum  before  the  muscular  structures  have  had  time  to 
dilate ;  whence  perineal  laceration,  which  is  extensive  in  proportion  to 
the  want  of  due  relation  of  these  forces.  Or  the  vagina  and  perineum, 
rigid  in  accordance  with  deficient  sexual  appetite  and  development, 
may  not  have  sufficiently  softened  in  pregnancy,  and  may  not  readily 
dilate,  so  that  in  the  passage  of  the  child  perineal  laceration  occurs. 

From  deficiency  of  dilatation  from  the  foregoing  causes  it  may  be 
necessary  that  assistance  by  the  forceps  be  given  to  the  passage  of  the 
child.     The  state  of  the  parts,  whether  of  the  cervix  or  perineum,  ren- 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     121 

ders  a  gradual  advance  most  appropriate ;  while  the  condition  and  feel- 
ings of  the  woman,  weary  and  in  excruciating  pain,  seem  to  indicate  the 
desirability  of  speedy  delivery.  Under  such  circumstances  the  forceps 
are  very  often  used  without  an  anaesthetic,  and  laceration  is  frequently 
thus  effected ;  even  if  the  head  have  not  passed  through  the  cervix  the 
forceps  may  be  made  to  draw  it  down  quickly,  after  which  the  increased 
pain  by  pressure  on  the  perineum  as  yet  unstretched  induces  the  at- 
tendant to  hurry,  and  a  few  minutes  only  may  be  given  to  dilatation 
in  place  of  the  two  hours  which  nature  would  have  employed.  But  if 
chloroform  be  given  these  influences  are  lessened,  dilatation  may  be 
quietly  effected,  and  laceration  prevented  or  limited. 

If  the  fresh,  raw  surfaces  at  the  cervix  or  perineum,  lacerated  deeply 
into  the  broad  ligament  or  recto-vaginal  connective  tissue  respectively, 
absorb  septic  germs,  a  pelvic  cellulitis  results  commensurate  with  the 
virulence  of  the  sepsis.  If  of  the  most  violent  type,  there  is  a  general 
suppurative  oedema  of  the  connective  tissue  and  suppurative  phlebitis, 
and  death  probably  ensues.  Or,  the  microbic  attack  being  less  virulent, 
a  suppurative  thrombus  may  be  impacted  in  a  vein,  guarded  toward  the 
heart  by  a  sufficiently  healthy  adherent  clot,  and  the  increasing  pus 
may  burst  through  the  venous  wall,  infecting  the  adjacent  connective 
tissue  and  presenting  in  the  direction  of  least  resistance :  if  the  mi- 
crobes be  detained  in  the  lymphatic  glands  a  similarly  localised  pelvic 
suppuration  may  occur.  A  local  necrosis  of  connective  tissue  at  the 
site  of  laceration  may  escape  by  the  genital  canal,  or  a  benign  inflam- 
mation terminate  in  resolution. 

The  morbid  influence  of  the  micrococci  is  effective  only  so  long  as 
the  power  of  the  septic  micro-organisms  is  greater  than  that  of  the 
phagocytes  and  leucocytes,  so  that  the  former  force  a  passage  into,  and 
are  carried  by  the  lympathic  and  blood  vessels  into  the  general  system  ; 
if  the  latter  presently  overpower  and  destroy  the  micrococci,  the  healing 
process  forms  granulations  guarded  by  an  army  of  victorious  cells,  and 
parasites  can  no  longer  gain  admission,  though  they  may  create  a  local 
superficial  suppuration  \yide  article  on  Inflammation]. 

It  is  not  rare  that  the  angle  of  laceration  in  the  cervix  has  been  so 
high  that  the  tension  of  the  growth  of  the  ovum  in  succeeding  pregnan- 
cies causes  such  irritation  as  exaggerates  the  normal  uterine  contrac- 
tions, and  miscarriage  or  premature  labour  results. 

The  appropriation  of  the  absorbing,  healing,  and  nutritive  action  of 
the  lymphatic  and  blood  vessels  in  such  inflammation  of  the  lacerated 
cervix,  at  the  expense  of  that  which  the  removal  and  renewal  of  the 
parts  requires,  usually  results  in  subinvolution  of  the  ligaments,  and  of 
the  muscular,  connective,  venous,  and  nerve  tissues  of  the  pelvis  and  gen- 
eral system  in  proportion  to  the  strength  of  the  inflammation,  its  extent, 
and  the  degree  of  its  subsequent  continuance  and  drain.  Should  lacer- 
ation of  the  perineum,  as  well  as  of  the  cervix,  have  occurred,  subinvolu- 
tion of  all  the  genital  strvictures  generally  results ;  if  only  of  the  one  or 
the  other,  then  of  the  parts  specially  allied  to  the  nutrition  of  that  one. 


SYSTEM   OF  GYNECOLOGY 


The  misplacements  which  may  arise  in  connection  with  subinvolu- 
tion are  described  in  section  3. 

The  subsequent  occurrence  of  sterility  or  pregnancy  is  dependent  on 
the  degree  to  which  the  cervical  circular  muscular  fibres  and  external 
cervico-vaginal  wall  are  lacerated,  effecting  more  or  less  eversion  up  to 
the  level  of  the  uninjured  canal ;  should  the  opening  in  such  complete 
lateral  laceration  be  narrowed  by  the  pressure  of  everted  cervical  mucous 
membrane  and  ensuing  hyperplasia,  Avhereby  the  normal  trumpet-shaped 
opening  is  lost,  the  sperm  cannot  enter,  and  sterility  results  ;  or  a  cer- 
vicitis and  endometritis  may  result  from  vaginal  friction,  and  mucous 
secretion  plug  or  fill  the  uterine  tube.  But  if  the  laceration  do  not 
extend  through  the  outer  wall  of  the  vaginal  cervix,  the  canal  may  be 
of  an  enlarged  trumpet-shape,  and  the  sperm  enter  with  unusual  readi- 
ness ;  or  the  end  of  the  penis  may  penetrate  such  a  canal,  and  directly 
inject  the  sperm  into  it,  effecting  rapidly  recurring  pregnancies. 

The  state  of  constant  excessive  proliferation  of  cells  of  low  type  by 
the  granular  hyperplastic  lacerated  cervix  is  most  favourable  to  the  de- 
velopment of  cancer,  which  is  further  discussed  in  section  C,  on  consti- 
tutional causes. 

Endometritis,  with  or  without  displacement  and  subinvolution  in  the 
parous,  having  been  induced  by  one  or  other  of  the  causes  previously 
mentioned,  or  by  the  action  of  special  microbes,  as  of  gonorrhoea  or 
puerperal  septicaemia,  some  thickening  toward  the  uterine  end  of  the 
Fallopian  tube,  which  is  only  of  the  size  of  a  fine  bristle,  takes  place 
by  extension  of  the  endometrial  inflammation  to  the  tubal  mucous  mem- 
brane and  the  consequent  obstruction  frequently  increased  by  stenosis 
of  the  cervical  canal,  which  mechanically  hinders  or  prevents  escape  of 
the  uterine  and  tubal  secretions. 

The  secretions,  accumulating  in  the  tube,  overflow  through  the  fimbria 
into  the  abdominal  cavity,  whereby  an  irritation  or  inflammation  of  the 
peritoneum  is  caused  proportionate  to  the  quantity  and  quality  of  the 
fluid  effused;  peritonitis  being  always  due  to  the  entrance  of  irritating 
matter  —  gaseous,  fluid,  or  solid — into  the  abdominal  cavity  directly,  or 
by  transudation  under  great  inflammatory  distension.  In  the  effusion  of 
a  bland  fluid  —  as  of  a  healthy  tubal  mucus,  mild  ovarian  follicular  fluid, 
small  quantities  of  blood  or  healthy  urine  —  the  irritation  may  not 
amount  to  more  than  an  excitation  of  the  peritoneal  endothelial  cells  for 
the  purpose  of  its  absorption,  and  the  fimbria  may  remain  free  and  unin- 
jured. (Jn  the  relief  of  an  existent  cervical  cause  of  endometritis,  such  as 
granular  eversion,  virginal  or  from  laceration,  the  tubal  stenosis  may 
cease;  and  the  tube  may  again  become  normal.  Should  the  effusion  be 
more  irritating  and  septic,  fibrin  is  exuded  by  inflammatory  action  of 
the  peritoneum ;  thickening  of  adjacent  structures,  or  adhesion  by  con- 
nective tissue  organisation  of  the  exuded  fibrin  occurs,  and  the  fimbria 
of  the  tube  liccoines  attached  and  closed ;  the  tubal  sccrcitions,  (;ollecting 
in  the  more  dilatable  niid-part  of  the  tube,  then  distend  it,  and  a  pyo- 
salpinx  is  formed.      Under  pressure  the  uterine  end  may  yield  and  the 


ETIOLOGY   OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     123 

pus  escape  through  the  genital  canal :  if  this  do  not  occur  and  the  bacterial 
virus  be  moderate  in  power  and  become  attenuated,  the  secretion  may 
not  increase  in  quantity ;  pus-cells  may  undergo  fatty  degeneration  and 
absorption,  and  a  more  or  less  stationary  hydrosalpinx  presently  result : 
or,  again,  if  the  healing  process  be  less  complete,  caseous  pus  may  persist. 
But  if  the  bacteria  be  virulent  in  quantity  or  quality  pus  continues  to 
collect,  and,  by  increasing  pressure,  a  gradual  thinning  of  the  tubal  wall 
at  the  site  of  least  resistance  takes  place.  As  the  inner  coats  of  the 
tube  break  down,  its  peritoneal  coat  yields,  and  presently  a  minute  per- 
foration permits  a  slight  effusion  into  the  peritoneal  cavity.  Thereupon 
an  exudation  of  fibrin  occurs  about  the  site  of  such  rupture,  and  the 
peritoneal  surfaces  of  the  tube  and  the  adjacent  viscus  (commonly 
intestine)  cohere.  As  the  tul)al  distension  continues  to  increase,  an 
opening  through  the  united  peritoneal  layers  into  the  viscus  occurs,  and 
the  pus  escapes  from  the  tube.  Through  this  opening,  or  by  penetration 
through  the  adherent,  inflamed,  distended,  thin,  intervening  structures, 
bacilli  from  the  viscus,  such  as  the  bacillus  pyogenes  foetidus  from  the 
intestine,  may  enter  the  tube  and  render  the  pus  foetid.  Sudden  pressure 
may  cause  rupture  directly  into  the  peritoneum  and  a  virulent  peritonitis. 
In  labour  the  pressure  of  the  foetal  head  may  rupture  the  pyosalpinx 
into  the  broad  ligament,  and  thus  extensive  suppurative  connective  tissue 
may  spread  in  the  direction  of  least  resistance,  the  vigour  of  the  extension 
being  dependent  on  the  character  of  the  bacillary  cause  of  the  tubal 
suppuration :  it  is  specially  virulent  in  gonorrhoeal  infection. 

Should  the  effusion  from  the  fimbria  be  of  a  virulent  character,  such  as 
septic  pus,  there  may  be  a  preliminary  slight  oozing  Avhich,  while  creating 
a  severe  inflammation  of  the  adjacent  peritoneum  at  the  site,  yet  permits 
the  exudation  of  organisable  fibrin  at  a  slight  distance,  so  that  the  fimbria 
becomes  encapsuled,  and  perhaps  adherent;  but  a  septic  abscess  may  thus 
be  originated  by  this  effused  pus  between  the  fimbria  and  the  adherent 
viscus ;  whence  arises  a  tubo-peritoneal  abscess,  which  may  be  tubo- 
ovarian.  If  there  be  more  extensive  peritonitis  with  distant  organised 
adhesions,  peritoneal  abscesses,  perhaps  saprous  by  intestinal  bacterial 
transudation,  may  be  formed ;  and  the  omentum,  by  lymphatic  absorption, 
may  be  studded  with  abscesses  and  adherent  to  the  abdominal  wall.  P>ut 
if  the  effusion  be  large  or  continuous  —  as  of  such  septic  pus,  when  organis- 
ing fibrin  has  not  been  exuded,  or  has  not  attached  and  occluded  the 
fimbria  on  accouut  of  the  virulence  of  the  effused  matter  —  tlie  peritonitis 
is  general  and  virulent,  and  the  exudation  sero-purulent  with  occasional 
cohering  fibrin-flakes. 

The  peritonitic  exuding  organising  fibrin  may  attach  adjacent  abdom- 
inal or  pelvic  surfaces,  as  those  of  the  uterus,  tubes,  ovaries,  intestines, 
vermiform  appendix,  omentum,  or  abdominal  or  pelvic  wall ;  or  form  bands 
like  floss-silk,  violin  strings,  or  tapeworm.  The  intestines,  during  the 
period  of  acute  inflammation,  are  comparativel,y  stationary,  except  for 
gaseous  distension;  but  during  the  period  of  convalescence  they  undergo 
considerable  alteration  in  position  by  vermiform  action.     The  connective 


124  SYSTEM   OF  GYNAECOLOGY 

tissue  adhesions  become  stretched  by  these  movements  of  the  intestines ; 
and,  later,  may  constrict  them,  and  produce  various  degrees  of  obstruction 
to  the  passage  of  flatus  or  faeces,  and  to  the  circulation  of  the  blood. 
BetAveen  extensive  organised  fibrinous  adhesions  serous  sacs  may  be 
formed,  either  by  the  presence  of  attenuated  bacilli  in  adjacent  peritoneal 
surfaces  and  irritation  of  them,  or  by  transudation  of  serum  from  veins 
constricted  by  bands  or  adhesions.  This  latter  condition  is  seen  when 
the  abdomen  is  opened  for  the  relief  of  intestinal  strangulation  caused 
by  such  a  band. 

By  the  organisation  of  the  exuded  fibrin  into  connective  tissue  the 
tubes  may  be  bound  down  at  the  fimbriae,  or  more  extensively  ;  or  the 
two  fijubriae  may  cohere  posteriorly.  Thus  they  are  in  future,  perhaps, 
unable  to  apply  themselves  to  the  site  of  the  mature  Graafian  follicle;  or 
one  may  be  thus  adherent,  and  the  other,  being  free,  may  apply  its 
fimbria  to  the  other  ovary  on  ovarian  maturation. 

The  irritation  produced  by  effusion  from  the  fimbria  of  the  tube  causes 
a  thickening  of  the  tunic  of  the  ovary  by  its  inflammatory  cell  multiplica- 
tion and  condensation ;  if  the  peritonitis  be  more  severe,  the  surface  may 
be  coated  with  exuded  organised  fibrin,  which  may  form  into  bands,  or 
be  densely  adherent  to  adjacent  peritoneum.  When  the  ripe  Graafian 
follicle  has  advanced  from  within  the  ovary  to  this  thickened  and 
condensed  surface  layer,  its  further  progress  is  thereby  impeded ;  the 
liquor  folliculi  may  increase  in  quantity  beyond  the  normal,  and  a 
haemorrhage  take  place  into  the  cavity  and  so  effect  its  rupture.  The 
ovarian  tunic  may  yield  under  this  increased  tension,  when  a  fimbria  may 
by  its  previous  affections  be  unable  to  apply  itself,  and  its  abnormal 
contents  may  thus  fall  into  the  abdominal  cavity.  By  the  stress  of 
such  a  follicle  on  the  ovary  an  undue  pressure  on  the  ovarian  stroma  may 
create  pain,  and  by  the  escape  of  the  contents  into  the  peritoneum  a 
peritonitis  be  caused.  The  opening  may  be  quite  minute,  or  door-like 
and  valvular  by  contact  with  the  adjacent  peritoneum,  so  that  the  fluid 
oozes  out  gradually ;  and,  the  irritation  causing  peritonitis  being  thus  con- 
tinuous, the  temperature  may  remain  high,  though  the  inflammation  be 
really  confined  to  the  locality  of  the  effusion.  Degrees  of  pyrexia  in  peri- 
tonitis seem  often  to  be  dependent  on  the  degrees  of  mildness  or  virulence 
of  the  eft'nsion,  and  on  the  excess  of  absorption  over  exudation.  It  is 
often  high  when  the  cause  is  mild,  and  absorption  by  the  lymphatics  into 
the  system  active;  normal,  when  the  effusion  is  virulent  and  peritonitic 
exudation  dominant ;  and  low  from  debility  and  shock,  if  a  large  quantity 
of  blood  \)fi,  poured  into  the  peritoneum  by  rupture  of  vessels. 

Such  ruptures  of  different  cysts  may  be  consecutive,  producing  recur- 
rent peritonitis;  and  should  ])loodbe  present  in  the  follicles,  the  irritation 
is  the  greater.  Frequently  rufjture  is  not  effected,  and  a  follicular  cyst 
remains  which  may  be  filled  with  blood  ;  this  is  possibly  more  generally 
the  case  when  the  maturity  of  the  follicle  has  l^een  coincident  with  men- 
struation or  sexual  union.  Such  follicular  cysts  may  attain  to  the  size  of 
a  walnut,  or  occasionally  larger  than  that;  and,  finally,  as  the  gradual 


ETIOLOGY   OF  DISEASES    OF  FEMALE    GENITAL    ORGANS     125 

increase  of  fluid  thins  and  ruptures  the  walls,  they  may  empty  themselves 
into  the  peritoneum  and  produce  peritonitis. 

By  the  continuance  of  pressure  of  these  cysts  the  ovarian  stroma  is 
permanently  compressed  and  atrophied;  and  the  ovary  may  be  com- 
posed of  little  more  than  such  sacs.  This  fluid  may  after  a  time  be 
absorbed,  when  the  ovary  by  contraction  of  the  sac-walls  will  appear 
to  be  cirrhotic;  but  the  outer  walls  of  the  cysts  remain  mainly  as 
connective  tissue  condensations. 

If  in  the  earliest  period  of  septic  infection  of  the  fimbria,  which  is 
usually  puerperal,  gonorrhoeal,  or  tuberculous,  its  effusion  have  had  time  to 
effect  a  peritoneal  exudation  causing  cohesion  of  the  fimbria  to  the  ovary, 
a  free  escape  into  the  peritoneum  may  have  been  prevented,  and  the 
fimbria  may  have  become  adherent  to  a  subsequently  ripening  Graafian 
follicle,  which  may  rupture  into  the  lumen  of  the  tube  :  the  septic  matter 
may  thus  enter  the  cavity  of  the  follicle,  and  lead  to  a  septic  abscess  of 
the  ovary  ;  or  bacteria  may  penetrate  the  thinned  wall  of  the  follicular 
cyst,  which  is  inflamed  by  contact.  The  farther  progress  of  abscess  of  the 
ovary  is  described  under  section  6,  as  its  causation  is  always  bacillary. 

When  tubal  disease  of  a  moderate  degree  is  in  progress  of  recovery, 
extra-uterine  foetation  may  occur.  The  disease  may  have  arisen  from 
endometritis,  however  caused ;  but  specially  from  the  virginal  gi'anular 
cervix  or  from  a  lacerated  cervix,  which  may  have  been  cured  by  opera- 
tion ;  or  it  may  have  had  a  gonorrhoeal  origin,  with  attenuation  of  the 
bacteria  under  conditions  of  free  uterine  drainage.  There  has  been 
stenosis  of  the  uterine  end  of  the  tube,  atid  perhaps  some  mild  peritonitis 
from  tubal  distal  effusion :  in  process  of  recovery  this  stenosis  has  been 
mitigated,  but  not  completely  removed,  and  the  semen  has  been  able  to 
enter  the  tube  and  impregnate  the  ovum.  If  the  outer  part  of  the  tube 
be  sufficiently  patent,  the  ovum  may  be  able  to  advance  to  the  portion 
within  the  uterine  Avail,  where  it  may  be  stopped  by  the  congestion  of 
fecundation  external  to  the  site  of  the  stenosis,  and  there  develop  as  a 
tubo-uterine  fetation.  Should  the  site  of  the  stenosis  be  more  external 
the  gestation  is  tubal. 

In  rupture  of  a  tubal  gestation  more  or  less  of  the  contents  of  the 
ovum,  with  blood  from  the  torn  chorionic  villi,  may  be  discharged  through 
the  fimbria  and  form  tubal  abortion ;  or  through  the  lateral  wall  into  the 
abdominal  cavity,  and  produce  peritoneal  hematocele  and  peritonitis, 
of  which  the  degree  and  progress  will  vary  Avith  the  quantity  of  blood 
lost  in  relation  to  the  bacilli  of  the  original  salpingitis,  which  probably 
escape  with  it  from  the  tube  external  to  the  envelope  of  the  ovum, 
and  the  subsequent  necrosis  of  the  ovum :  or  again  into  tlie  broad  liga- 
ment, forming  a  haematocele  in  its  connective  tissue,  the  blood  forcing 
its  way  in  the  direction  of  least  resistance,  and  perhaps  suppurating 
under  the  influence  of  bacilli  introduced  from  the  tube,  which  may 
throughout  have  remained  mildly  septic  from  the  original  causation 
of  its  disease. 

If  the  quantity  of  blood  lost  by  such  rupture  be  so  slight  that  the 


125  SYSTEM   OF  GYNECOLOGY 


ovum  survives,  the  subsequent  condition  is  that  of  a  compound  abdomi- 
nal pregnane}',  with  such  rehxtions  of  tlie  phxcenta  as  are  determined 
by  its  situation,  either  below  the  foetus  toward  the  floor  of  the  pelvis 
or  above  it  in  the  abdominal  cavity. 

The  pressure  of  the  enlarged  tube  or  ovary  may  push  the  uterus 
over  to  the  opposite  side,  effecting  latero-version,  from  which  there 
may  be  recovery  on  subsidence  of  the  tumour.  Or  a  peritonitic  exuda- 
tion from  tubal  or  ovarian  effusion,  or  a  heematocele  may  similarly 
displace  the  uterus  to  the  opposite  side;  but,  on  absorption  and 
organisation,  the  uterine  body  may  be  drawn  over  by  the  condensed 
exudation  and  permanently  retained  on  the  affected  side. 

C.  The  hereditary  constitutional  defects,  in  which  certain  classes 
of  cells  morbidly  proliferate,  are  dermoid  tumour,  parovarian  cystoma, 
cystoma  of  Gartner's  tubes,  ovarian  cystoma,  papilloma,  myoma,  sar- 
coma, and  cancer. 

By  "  Constitutional "  is  not  meant  that  the  disease  will  certainly  or 
probably  occur  because  of  heredity,  but  that  there  is  a  constitutional 
capacity  for  such  cell  proliferations,  should  the  parts  be  placed  under 
suitable  exciting  causes.  Thus,  as  to  the  development  of  cancer  from 
the  continuous  irritation  of  a  granular  cervix,  the  latter  may  in  some 
cases  persist  to  the  end  of  a  long  life  and  remain  benign ;  in  others, 
where  there  is  a  constitutional  capacity  of  such  cell  degeneration,  it 
readily  becomes  malignant. 

The  etiology  of  the  dermoid  tumour  is  attributable  to  the  origin  and 
mode  of  development  of  the  ovary.  From  the  mesothelial  division  of 
the  mesoderm  are  formed  the  ovary  and  striated  muscle;  from  the 
mesenchyma,  which  is  the  other  division  of  the  mesoderm,  come  the 
connective  tissue,  the  heart  and  blood-vessels,  lymphatics,  smooth 
muscle,  fat  cells,  and  the  skeleton.  The  dermal  bones,  which  are  those 
of  the  head  and  face,  and  are  most  frequent  in  dermoid  cysts,  are  formed 
l)y  direct  ossification  of  connective  tissue;  they  are  homologous  witJi 
the  jdates  formed  by  the  fusion  of  epidermal  teeth,  or  of  the  so-called 
placoid  scales  which  are  true  teeth  developed  in  the  skin  and  supported 
by  a  base  of  bone  :  of  them  there  is  the  stage  of  scattered  independent 
dermal  teeth  (dermoid  scales) ;  teeth-bearing  plates  formed  by  the  fusion 
of  the  expanded  bases  of  adjacent  teeth  (exo-skeleton) ;  and  membrane- 
bones  developing  without  the  appearance  of  teeth.     (Minot.) 

The  mesothelial  layer  of  the  mesoderm  is  closely  connected  with 
the  ectoderm ;    the  mesenchyma  with  the  entoderm. 

From  the  ectoderm  are  developed  epidermis  and  epidermal  structures, 
such  as  hairs,  nails,  glands  (sebaceous,  sudorific,  salivary,  and  mammary, 
the  mammary  being  a  hyper-development  of  the  sebaceous),  the  eye,  and 
the  mouth-cavity  with  the  teeth ;  all  of  which  structures  are  occasionally 
found  in  the  dermoid  cyst.  Thus  in  the  formation  of  the  dermoid  ovum 
some  mesenchymatous  and  etitodiirmal  cells  have  by  migr;i,tion  been 
incoi-porated  with  the  mesotlielial,  and,  continuing  a  constitutional 
aVni'inn.'il    'n-owl!],   originate  and   ijroduce  the  contents. 


ETIOLOGY    OF  DISEASES    OF  FEMALE    GENITAL    ORGANS     127 

A  projecting  dermal  bone  may  perforate  the  sac  wall  and  produce 
peritonitis,  whereby  the  adjacent  structures  cohere  so  that  bones  and 
other  contents  may  escape  through  the  bladder  or  intestine ;  but  the 
sac  probably  inflames  on  the  admission  of  bacteria. 

After  the  period  of  vital  activity  and  growth  of  the  contents  of  the 
tumour,  growth  may  cease  by  deficiency  of  nutrition,  caused  by  bending 
of  its  vessels  from  the  pressure  of  the  tumour,  or  by  the  diminished  size 
of  the  blood-vessels  after  the  menopause;  retrogression  may  then  set  in 
and  pass  through  a  stage  of  fatty  degeneration,  absorption,  and  calcare- 
ous transformation  of  the  sac  wall  and  its  contents  which  may  thus 
become  atheromatous  or  calcareous.  Crowding,  by  excessive  local  cell 
proliferation  occluding  small  vessels,  may  produce  necrosis  of  some  part, 
as  of  a  sebaceous  gland,  whereby  suppuration  within  the  sac  may  be 
induced ;  the  pus  may  become  foetid  by  transudation  through  inflamed 
distended  adherent  sac-intestinal  walls,  or  by  the  direct  admission  of 
putrefactive  germs  from  adjacent  adherent  perforated  intestine,  or  by 
operative  septic  puncture.  Or  suppuration  may  proceed  from  the  irrita- 
tion, inflammation,  rupture,  and  necrosis  from  excessive  proliferation  of 
a  papilloma  within  the  dermoid,  either  on  the  inner  wall  of  the  sac  or 
on  dermal  plates :  or  by  further  cell  degeneration  cancer  may  ensue. 

The  parovarian  cyst  is  caused  by  an  embryonic  deficiency  of  absorp- 
tion, and  a  subsequent  hypertrophic  glandular  secreting  development  of 
the  granular  cylindrical  lining  cells,  which  normally  remain  quiescent  in 
the  sexual  part  of  the  female  rudimentary  Wolffian  ducts  situated  in  the 
connective  tissue  of  the  broad  ligaments.  In  the  early  eiubryonic  state 
the  future  male  is  indistinguishable  from  the  future  female.  In  the 
male  the  developed  epididymis  is  the  analogue  of  the  atrophied  epooph- 
oron  or  parovarium  of  the  female.  The  epididymis  is  lined  with  colum- 
nar epithelium  ;  and  a  continuation  of  this  layer  with  secreting  power, 
and  deficiency  of  resorption  or  atrophy  in  relation  to  hypernutrition, 
originates  the  parovarian  cystoma.  It  is  probably  a  continuance  of  or  a 
reversion  to  an  embryonic  or  local  hermaphroditic  type.  In  its  enlarge- 
ment it  parts  the  walls  of  the  broad  ligament,  and  spreads  out  upon  its 
surface  the  Fallopian  tube  and  fimbria,  and  later  the  ovary;  it  may 
extend  deeply  into  the  connective  tissue  layer  of  the  pelvis,  or  on  the 
uterus.  As  the  cells  lining  the  sac  have  but  slight  power  of  proliferation, 
probably  from  defective  nutrition  of  a  structure  normally  in  arrest  of 
development,  the  sac  wall  is  very  thin  ;  and  there  is  no  ingrowth,  for  this 
is  not  the  mode  of  its  analogue,  the  epididymis,  nor  of  antecedent  phases  : 
thus  the  cyst  is  unilocular,  unless  by  cystic  development  of  more  tubules 
of  the  parovarium ;  and  veins  do  not  become  varicose  and  rupture  inter- 
nally, unless  by  rotation  of  the  pedicle,  or  their  kinking  under  pressure 
of  the  tumour.  For  the  same  reason  secondary  growths,  such  as  papil- 
loma, which  require  local  hypernutrition,  are  rare. 

A  cystic  tumour  situated  laterally  in  the  vagina  may  have  its 
origin  in  a  similar  state  of  one  of  Gartner's  tubes,  which  are  the  lower 
parts  of   the  atrophic  Wolffian  ducts,  are  the  analogue  of   the   male 


128  SYSTEM  OF  GYNECOLOGY 

adxilt  spermiduct  and  vesiculce  seminales,  and  run  through  the  genital 
cord. 

As  to  the"  etiology  of  ovarian  cystoma,  in  the  development  of  the 
ovary  portions  of  its  external  germinal  columnar  epithelium  grow  in- 
wards, and  some  of  these  cells  become  ova ;  while  deeper  multiplied  cells 
of  the  same  description  form  the  membrana  granulosa  of  the  Graafian 
follicles.  The  normal  function  of  these  cells  is  to  conduce  to  the  nutri- 
tion and  further  development  of  the  ovum,  which  has  the  highest  poAver 
of  progressive  development  in  the  body.  But  it  occasionally  happens 
that  the  tendency  to  continuous  proliferation  of  the  cells  of  this  layer  is 
greater  than  the  subserviency  to  perfection  of  growth  of  the  ovum,  and 
their  multiplication  is  in  excess.  At  the  same  time  the  inner  cells 
rupture  and  pour  their  secretion  internally ;  by  such  continuous  process 
an  ovarian  cystoma  is  formed,  which  persistently  enlarges.  It  is  a 
constitutional  degeneration  into  a  glandular  secreting  structure. 

As  the  cells  of  the  germinal  epithelium  do  not  all  arrive  at  the  produc- 
tion of  the  complete  Graafian  follicle,  but  there  are  many  less  well- 
nourished  primitive  ova  embedded  in  the  stroma,  it  is  possible  that,  while 
the  better-nourished  cells  of  the  membrana  granulosa  are  most  apt  to 
undergo  this  degeneration  and  the  cystoma  to  be  formed  originally  in  a 
Graafian  follicle,  those  in  the  stroma  may  also  proliferate  in  a  similar 
manner  under  the  influence  of  the  existing  constitutional  tendency. 

In  this  growth,  morbid  in  man,  may  be  seen  a  strong  analogy  to  the 
development  of  the  ova  and  the  yolk-food  in  some  lower  creatures.  In 
them  from  the  inner  wall  of  the  germinal  plasma  grow  cells,  usually 
columnar  in  character,  which  form  (a)  ova,  or  (h)  germinal  cell-nests ;  f roin 
among  these  one  or  more  ova  may  be  produced,  while  the  rest  of  the  cells 
serve  as  yolk- food  and  disintegrate.  The  number  of  ova  in  some  creatures 
—  as  nine  millions  in  the  cod,  three  to  six  millions  in  the  conger  (7,  9), 
and  seventy  thousand  in  the  woman  —  is  frequently  prodigious.  The  sac 
membrane  may  bud  off  internally,  and  form  lamina3  and  branches  for 
further  cell  proliferation  on  their  walls,  and  subdivision  of  the  ovarian  sac. 
These  partitions  may  break  down  to  permit  extrusion  of  the  ripe  ova. 
Some  creatures,  as  for  instance  the  conger,  breed  only  once,  and  die  by 
the  enormous  distension  of  the  body  by  accumulation  of  ova,  which,  in 
captivity,  are  incapable  of  escape.  In  ovarian  cystoma  the  multiplication 
of  cells  thus  closely  simulates  and  is  analogous  to  similar  proliferaticm  in 
lower  creatures,  either  as  primitive  ova-cells,  or  as  germinal  cell-nests, 
undergoing  progressive  degeneration  ;  and  may  be  regarded  as  a  morbid 
hypertroi)hic  germ-plasma  cell  proliferation  reversionary  to  an  anterior 
type.  Altliougli  children  have  been  born  with  this  disease,  and  occasional 
instances  arc  found  in  the  early  years  of  life,  when  the  condition  may 
be  rogai'dcd  as  one  of  defective  development,  it  is  most  commonly 
found  to  coiiiiiience  during  the  years  of  strong  generative  ovic  vitality; 
and  many  patients,  nearly  a  third,  are  single.  Jt  is  thus  jn-obable  that 
ovarian  cystoma  is  a  degenerative  reversionary  proliferation  of  the  ger- 
minal ovic  epithelium  (akin  to  that  of  the  unstriped  muscular  and  connec- 


ETIOLOGY   OF  DISEASES    OF  FEMALE    GENITAL    ORGANS     129 

tive  cells  occurring  in  myoma),  in  relation  to  absence  or  deficiency  of  their 
normal  employment,  namely,  the  production  of  the  next  generation. 

The  degeneration  being  thus  of  a  type  whicli  affects  the  develop- 
ment of  all  the  cells  of  this  class,  the  disease  does  not  attack  one  fol- 
licle only,  but  is  common  to  all ;  not  necessarily  at  the  commencement, 
but.  subsequently.  Hence  a  cystoma,  on  its  attainment  of  some  size,  is 
almost  always  multilocular ;  one  sac  may,  however,  by  appropriation  of 
the  most  nutrition,  attain  to  the  greatest  size. 

By  ingrowths  of  the  lining  columnar  cells  a  cyst  may  be  divided, 
and  by  such  repetitions  it  becomes  additionally  multilocular.  By  the 
thinning  and  rupture,  or  the  necrosis  of  a  partition  by  excessive  press- 
ure of  the  fluid  on  one  or  both  sides  respectively,  two  cysts  may  become 
one.  By  varicosity  of  veins  induced  by  the  pressure,  which  is  fre- 
quently at  the  junction  of  the  tumour  with  the  pedicle,  or  by  pressure 
of  adjacent  rapidly  grooving  cysts  on  a  vein,  the  rupture  of  a  vein  may 
occur ;  and  one  or  more  cysts  in  a  multilocular  tumour  may  be  filled  with 
blood.  By  similar  partial  pressure  on  the  arteries  and  veins  reducing 
nutrition,  fatty,  purulent,  or  calcareous  degeneration  of  the  lining  cells 
and  thus  of  the  contents  results,  whether  of  one  or  more  of  the  cysts. 

By  some  kind  of  changing  pressure,  such  as  manipulation,  descent 
of  fseces,  vigorous  alteration  of  position,  or  tension  of  or  pressure  on 
the  tumour  as  in  lying,  or  by  the  growth  of  the  pregnant  uterus,  or 
in  parturition,  or  on  removal  of  pressure  as  after  parturition,  or  on 
change  in  form  of  the  tumour,  as  by  the  emptying  of  a  large  cyst 
in  a  multilocular  tumour  by  tapping,  rotation  of  the  tumour  may  take 
place,  and  the  pedicle  be  twisted  —  an  event  which  may  similarly,  by 
the  same  or  similar  causes,  be  many  times  repeated;  thereby  the  ves- 
sels are  liable  to  be  occluded.  Partial  closure  both  of  arteries  and 
veins  limits  circulation  and  nutrition,  and  may  materially  restrict  the 
development  and  growth  of  the  tumour.  But  the  circulation  is  less 
obstructed  in  the  arteries  than  in  the  veins ;  whence  may  result  ascites 
from  serous  effusion  through  the  coats  of  the  latter  on  the  external  Avail 
of  the  tumour ;  or  veins  may  rupture  externally  or  internally,  but  in  a 
limited  degree  for  the  tension  is  not  severe.  If  externally,  the  blood 
coagulates  between  the  sac  wall  and  the  adjacent  peritoneum;  these 
cohere,  vessels  form,  and  the  venous  return  is  thus  facilitated,  and  the 
vitality  of  the  tumour  perhaps  preserved.  The  adhesions  prevent 
further  rotatio^i  of  the  tumour,  which  may  have  been  partial,  so  that  the 
cyst  may  occupy  a  fixed  position  on  the  side  opposite  to  its  own.  Such 
adhesions  restrain  the  movements  of  intestine  and  omentum  to  which 
they  may  be  attached ;  and  varying  degrees  of  obstruction  to  the  passage 
of  flatus  and  fa3ces  may  be  produced :  at  a  later  stage  stretched  bands 
may  tightly  constrict  the  bowel,  strangulating  it,  compressing  the  veins, 
and  causing  actual  rupture  or  serous  effusion  from  them  into  the  abdom- 
inal cavity.  The  future  groAvth  nuay  be  slow,  and  is  subject  to  these 
adhesions;  and  perhaps  not  till  an  advanced  period  of  life  are  such 
results  produced  that  the  presence  of  the  tumour  is  first  discovered. 

K 


SYSTEM  OF  GYNECOLOGY 


Should  the  veins  be  occluded  by  a  more  complete  or  more  repeated 
rotation,  an  intense  engorgement  immediately  occurs ;  veins  on  the 
interior  of  the  cyst  wall  rupture,  and  the  sac  is  tilled  with  blood, 
whereby  sudden  enlargement  and  perhaps  rupture  of  the  sac  take  place ; 
the  abdominal  cavity  may  then  be  filled  with  blood  and  ovarian  fluid, 
and  the  woman  faint  or  die.  If  there  be  venous  rupture  also  on. the 
outside  of  the  sac,  but  without  rupture  of  the  sac,  peritonitis  and  adhe- 
sions occur,  which  partly  nourish  this  surface :  the  tension  of  the  walls 
effects  their  necrosis ;  and  by  transudation  of  the  necrosed  fluids  through  ' 
the  distended  sac  wall  into  the  abdominal  cavity  an  acute  or  chronic 
peritonitis  will  result  proportionate  to  the  predominance  of  absorption 
or  exudation  :  these  factors  are  determined  by  the  quality  and  quantity 
of  the  fluid  transuding,  and  by  the  degree  of  internal  tension. 

If  the  arteries  and  veins  be  closed  at  once  by  the  compression  of  a 
twist,  no  more  blood  enters  the  tumour,  and  it  tends  to  necrose  by  lack 
of  nutrition.  As  it  necroses,  transudation  of  its  fluids  produces  peri- 
tonitis, and  fibrin  is  exuded  which,  by  its  development  of  vessels,  may 
effect  such  a  nutrition  as  to  maintain  just  so  much  vitality  of  its  sur- 
face cells  that  a  slow  absorption  occurs ;  the  tumour  decreases  in  size, 
and  remains  in  a  stagnant  condition.  Such  complete  closure  of  arteries 
is  rare  in  comparison  with  that  of  veins,  as  these  are  more  readily  com- 
pressed by  an  earlier  rotation. 

By  a  continuous  pressure  on  a  bony  angle  —  as  on  the  sacral  prom- 
ontory —  of  a  tumour  of  which  a  part  occupies  the  sacral  cavity,  and 
part  of  the  abdominal  cavity,  there  may  be  by  limitation  of  circulation  a 
thinning  of  the  sac  wall  at  this  site  which  may  result  in  necrosis ;  rupt- 
ure may  occur,  and  the  fluid  escape  into  the  abdominal  cavity.  The 
same  result  may  follow  extreme  distension  from  venous  rupture  due  to 
a  twisted  pedicle,  or  from  a  sudden  blow,  or  fall.  If  the  fluid  itself  be 
bland  the  resulting  peritonitis  may  be  slight,  but  more  or  less  pro- 
gressive according  to  its  quality  and  quantity,  and  the  degree  of  infect- 
ing necrosis  which  may  presently  occur  in  the  ragged  edges  of  the  torn 
wall,  combined  with  the  influence  of  systemic  depression  and  abdominal 
pressure  effected  by  the  haemorrhage  from  vessels  which  may  also  be  torn. 

A  further  degenerative  cell  multiplication  may  induce  papilloma ; 
and  one  still  lower,  cancer,  with  peritonitis  by  invasion,  haemorrhage 
and  serous  effusion  into  the  peritoneum. 

Papilloma  of  the  genital  organs  —  wliich  is  a  progressive  multiple 
development  of  ectodermal  or  entoderm al  epithelium,  enclosing  a  vas- 
cular loop  formed  of  a  capillary  terminating  in  a  small  vein  and  thus 
forming  a  papilla  —  is  liable  to  be  produced  by  an  irritation  which 
induces  an  increased  growth  in  any  part  of  the  genital  organs.  About  the 
vulva  the  cause  may  be  the  irritation  of  syphilitic  discharge;  at  the  ori- 
fice of  the  urethra,  of  the  friction  of  coition  or  masturbation,  or  exposed 
urethral  membrane;  in  the  bladder,  of  urinary  crystals  or  decomposi- 
tion ;  in  the  vagina,  occasionally,  the  hypernutrition  of  pregnancy  ;  and 
in  otlier  parts  of  the  genital  organs  —  as  in  the  uterus,  tubes,  ovaries,  and 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     131 

in  their  tumours  and  peritoneal  coverings  —  papilloma  may  arise  from 
local  irritation  and  vascular  proliferation.  In  connection  Avitli  all  internal 
papillomas  the  veins  are  liable  to  be  large  and  varicose  by  direct  pressure  or 
bending  on  the  cardiac  side.  When  occurring  on  the  internal  aspect  of  a 
cyst,  by  complete  local  venous  obstruction,  or  perhaps  from  deeper  exces- 
sive cell  proliferation,  papilloma  may  undergo  limited  necrosis  and  thus 
suppurate.  On  the  peritoneum,  friction  of  its  delicate  structures  usually  pro- 
duces serous  effusion,  and  perhaps  haemorrhage,  into  the  abdominal  cavity. 

Myoma,  which  is  a  proliferation  of  unstriated  muscular  fibres  enclosed 
in  a  connective  tissue  capsule,  and  usually  multiple,  is  attributable  to 
absence  of  pregnancy,  from  whatever  cause,  in  a  woman  of  strong  sexual 
development :  the  nutrition,  which  should  be  absorbed  in  the  devel- 
ment  of  the  pregnant  uterus  and  foetus,  is  expended  in  the  morbid  local 
])roliferation  of  muscular  fibres. 

While  the  muscular  fibre  proliferation  has  proceeded  a  sac  has  been 
formed  also,  usually  by  a  similar  multiplication  of  connective  tissue 
cells,  which  surrounds  the  m^^oma,  enlarges  with  the  progress  of  the 
muscle  fibres,  and  yet  maintains  such  strength  as  continually  to  con- 
strict the  supplying  vessels  and  retard  the  growth.  Yet  this  is  not 
necessarily  the  case ;  for  occasionally  a  myoma  rapidly  grows  in  the 
absence  of  synchronous  connective  sac  development,  and  has  the  exact 
form  and  red  appearance  of  the  pregnant  uterus ;  and,  in  the  oedema- 
tous  myoina,  the  rapid  enlargement  by  serous  or  lymphatic  infiltration 
of  the  inner  structures  so  distends  and  softens  the  sac  that  its  density 
is  diminished.  In  the  former  unrestricted  form  is  seen  the  more  exact 
tendency  toward  the  pure  uterine  growth  of  pregnancy,  though  the 
stimulation  of  the  ovum  is  absent. 

The  effects  of  such  diseases  depend  upon  the  situation  of  the 
original  fecundity  of  the  muscular  growth,  and  thus  of  the  direction  of 
increase  and  prominence  of  the  tumour.  If  such  situation  be  nearer 
the  endometrium  the  direction  of  least  resistance  is  toward  the  cavity 
of  the  uterus,  and  the  tendency  is  to  the  polypoid  form  ;  by  recurrent 
rotation  due  to  muscular  contraction,  a  long  thin  pedicle  may  be  formed, 
the  vessels  of  which  by  such  continuoiis  pressure  may  become  occluded, 
and  the  polypus  die  and  become  septic ;  or  muscular  contraction  may 
expel  the  polypus  into  the  vagina.  If  more  central  the  tumour  is  inter- 
stitial. If  in  the  external  part  of  the  muscular  wall  it  grows  outwards ; 
when  also  the  pedicle  may  gradually  be  lengthened,  thinned,  and  com- 
posed only  of  vessels  covered  with  peritoneum :  or  it  may  be  divided, 
cither  by  the  drag  of  its  impaction  in  the  pelvis  while  the  myomatous 
body  grows  upwards,  or  by  compression  of  the  pedicle  against  the  sacral 
]»r()montory,  or  again  by  rotation  of  the  subperitoneal  tumour.  The 
pelvic  tumour  thus  separated  may  either  undergo  a  vital  degeneration 
l)y  the  encroachment  of  connective  tissue  adhesions  resulting  from  the 
pciitcmitis  induced  in  the  process  of  the  occlusion  of  the  vessels  of  the 
pedicle;  or  may  necrose,  inducing  peritonitis  and  septic  absorption. 

By  cessation  of  arterial  supply.  produciMl  by  pressure  on  the  vessels 


132  SYSTEM  OF  GYNECOLOGY 

by  the  tension  of  the  connective  tissue  capsule  of  the  tumour,  generally 
interstitial,  the  central  cells  may  be  so  deprived  of  nutrition  that  they 
necrose ;  if  the  nutrition  be  deficient,  but  still  exist  to  some  degree,  a 
degeneration,  fatty,  purulent,  or  calcareous,  may  occur.  If  the  veins  be 
partially  compressed  at  some  point,  or  in  the  progress  of  growth  of  the 
tumour  be  kinked,  the  distal  parts  become  varicose,  and  the  tumour 
from  -n-hich  they  are  efferent  may  become  oedematous.  Cysts  may  also 
be  formed  b}'  the  rupture  of  veins  from  a  similar  cause  into  the  myoma- 
tous substance,  when  the  cavities  thus  formed  may  be  found  to  contain 
blood ;  or,  later,  after  absorption  of  the  colouring  matter,  a  straAv-col- 
oured  fluid.  By  occlusion  of  the  veins  of  the  uterine  cavity  by  pressure 
of  a  submucous  or  encroaching  interstitial  myoma  their  walls  may  rupt- 
ure, and  haemorrhage,  called  menorrhagia,  result :  this  is  particularly 
apt  to  occur  at  the  menstrual  epoch,  when  the  veins  are  specially  en- 
gorged ;  but  it  may  be  continuous,  in  relation  to  the  continued  pressure  ; 
or  recurrent,  when  the  blood  has  been  reformed  :  in  the  intervals  fibrin 
may  escape,  which  may  be  coagulated  or  not.  With  this  there  may  be 
intense  dysmenorrhoea  from  the  small  size  of  the  external  uterine  open- 
ing, which  latter,  indeed,  may  have  been  the  original  cause  of  the  steril- 
ity, and  so  of  the  myoma. 

By  similar  obstruction  to  lymphatics,  so  that  their  spaces  dilate  and 
may  become  of  considerable  size,  the  tumour  is  rendered  myomato-cys- 
tic ;  through  rupture  of  the  cyst  walls  large  yellowish  coagulated  clots 
of  their  secretion  may  escape  by  the  uterine  canal.  Thus  in  the  same 
specimen  may  be  found  an  oedematous  as  well  as  a  hard  myoma,  the 
condition  of  either  being  dependent  on  the  individual  relation  to  ob- 
structed veins  or  lymphatics,  or  both. 

Suppuration  may  follow  septic  puncture. 

The  encroachment  of  myoma  in  direct  growth,  or  combined  with 
artificial  abdominal  pressure,  by  bending  the  uterine  ends  of  the  Fallo- 
pian tubes,  frequently  occludes  them,  so  that  the  secretions  cannot 
escape  along  the  genital  canal.  Tubal  distension  then  occurs,  and  there 
is  presently  some  effusion  at  the  fimbriae,  whereby  is  produced  a  peri- 
tonitis proportionate  to  the  quantity  and  quality  of  the  effused  fluid. 
Fibrin  may  be  thus  exuded,  and  such  adhesions  formed  as  bind  down 
the  fimbriae  and  occlude  this  extremity ;  thus  the  mid-tube  may  become 
dilated  V»y  subsequent  collection.  Should  the  tube  lie  septic  or  gonor- 
rhfjeal,  the  further  progress  is  that  of  py()sali)inx,  whicli,  by  rupture,  may 
cause  a  fatal  peritonitis.  Or,  the  tumour  in  its  growth  may  spread  out, 
elongate,  and  flatten  the  tubes,  and  render  the  fimbriae  oedematous :  a 
frequent  local  peritonitis  may  occur  from  their  congestion  and  effusion. 

Myoma  frequently  and  when  of  any  size  usually  compresses  the 
ovaries,  so  that  they  perform  their  functions  with  difficulty  ;  and  local 
peritonitis  occurs  Vjy  the  rupture  of  the  irritated  ({raaiian  follicles  into 
the  peritoneum,  since  on  account  of  the  pressure  the  tul)f's  cannot  apply 
themselves.  As  their  tunics  have  previously  become  thi(^kened  by  tiie 
peritonitis  induced  by  the  fimbrial  effusion  above  described,  as  well  as 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     133 

by  that  resulting  from  their  own  rupture,  the  follicles  presently  fail  to 
rupture,  and  follicular  cysts  are  produced,  which  undergo  further  evolu- 
tionary changes.  The  continuous  degenerative  irritation  may  induce 
malignant  disease,  which  indeed  is  particularly  liable  to  originate  in  the 
endometrial  glands. 

Myoma  may  occur  in  the  ovary,  by  similar  lack  in  sterile  women  of 
normal  utilisation  of  blood  ;  and  an  excessive  development  of  connective 
and  fibrous  cells  may  produce  a  fibroma  of  the  uterus  or  ovary. 

Sarcoma,  originating  in  connective  tissue  derived  from  the  meso- 
derm, has  as  its  cause  the  constitutional  tendency  to  multiplication  of 
embryonic  connective  fibre  cells;  when  of  the  ovary,  it  is  perhaps  a 
morbid  reversion  to  a  lower  type  in  the  direction  of  the  formation  of 
ovarial  laminge,  which  have  not  the  capacity  of  development  into  the 
higher  connective  tissue  structure :  there  is  proliferation  without  organ- 
isation. The  ovary  is  occasionally,  though  rarely,  thus  affected,  and 
apparently  in  relation  to  sterility. 

Cancer,  which  is  a  continuous  cell  proliferation  of  amoeboid  type 
invading  the  lymphatic  spaces  and  vessels,  and  always  originating  in 
epithelium  derived  from  the  ectoderm  or  entoderm,  has  its  cause  in 
such  conditions  as  induce  excessive  formation  of  cells  of  degenerating 
quality.  Should  the  constitutional  state  permit  such  degeneration  to 
descend  to  the  lowest  amoeboid  type,  constant  multiplication  takes  the 
place  of  evolution;  and  this  tendency  is  exaggerated  by  the  occurrence 
of  obsolescence,  and  therefore  of  defective  nutrition  of  these  organs,  at 
the  most  common  period  of  cancerous  development ;  namely,  at  or  about 
the  menopause.  Such  sites  and  conditions  are  exceedingly  common 
in  the  chronic  granular  hyperplastic  face  of  the  lacerated  cervix,  in 
which,  unless  healed  by  operation,  cell  proliferation  terminates  only 
with  life ;  and  the  cancerous  degeneration  is  possible  at  any  time.  In 
endometritis  the  same  chronic  glandular  irritation  may  persist;  and 
ensuing  malignant  disease  occur  but  a  few  months  after  parturition  in 
young  women  from  hypernutrition  and  excessive  cell  proliferation  ^\ith 
degeneration  at  the  placental  site  from  puerperal  deciduoma;  changes 
which  may  be  associated  with  frequent  haemorrhages,  leucorrhoea,  subin- 
volution, and  constitutional  tendency  to  cell  multiplication  of  rapidly 
descending  cell  type.  Or  the  cancerous  phase  may  be  delayed  in  less 
feeble  capacity  of  cell  organisation,  but  be  attained  by  a  slower  yet 
progressive  exhaustion  through  the  same  constant  drain  on  the  system. 
But  cancer  is  less  frequent  in  the  body  of  the  uterus,  a  part  which  is 
not  exposed  to  the  friction  against  the  vagina,  a  friction  which  irritates 
the  granular  cervical  face,  and  thus  increases  cell  production.  Nor  does 
it  occur  on  the  granular  laceration  of  the  prolapsed  cervix,  because  cell 
proliferation  there  is  greatly  limited  l)y  the  dryness  of  the  situation. 

The  continued  irritation  of  a  myoma  may  produce  a  constant  pro- 
liferation of  a  primary  or  embryonic  type.  Should  this  occur  in  the 
connective  tissue  element  a  sarcoma  of  the  round-celled  variety  is  pro- 
duced ;  if  in  the  musculo-connective  tissue  the  sarcoma  is  spindle-celled; 


134  SYSTEM  OF  GYNECOLOGY 

if  in  the  glandular  structiu-es  of  the  endometrium  a  cylindrical-celled 
epithelioma  may  arise. 

By  the  invasion  of  the  lymphatic  vessels,  and  pressure  on  veins  by 
the  excessive  multiplication  of  cells,  oedema  and  local  haemorrhage  result. 
The  continuous  increase  presently  so  occludes  the  arteries  that  central 
necrosis  is  produced ;  at  the  periphery  of  this  the  open  ends  of  the  vessels 
may  bleed  extensively  from  inability  of  their  muscular  layer,  which  is 
infiltrated  by  the  cancerous  cells,  to  contract.  Nature's  endeavour  to 
separate  the  slough  towards  the  outer  edge  of  the  continuous  low  cell 
proliferation  —  a  proliferation  too  degraded  in  character  to  form  healing 
granulations  —  when  retained  in  healthy  passages,  as  in  the  vagina,  re- 
sults in  a  dirty  foetid  discharge,  which  is  in  some  degree  absorbed ;  thus, 
and  by  haemorrhage,  the  system  is  drained,  enfeebled,  and  poisoned. 

The  excessive  cell  proliferation,  around  the  nerves  as  Avell  as  in  the 
substance  of  them,  effects  such  compression  of  them  that  intense  agony 
ensues ;  this  is  worse  at  night,  either  because  the  recumbent  position 
increases  the  weight  on  the  nerves,  or  because  the  nervous  system,  at  this 
time  exhausted  by  the  waste  during  the  day,  is  less  resistent  to  the  prop- 
agation of  the  diseased  actions.  This  pain  is  usually  referred  to  the 
lumbar  region  at  the  site  of  the  entrance  of  the  vaginal  and  pelvic  plexus 
to  the  spinal  cord. 

The  pressure  of  the  tumour  on  the  adjacent  bladder  and  rectum  may 
impede  the  passage  of  their  excretions,  and  thus  abdominal  distension 
by  gas  and  retention  of  faeces  may  affect  the  appetite  and  digestion. 

Extension  of  the  disease  to  the  peritoneum  by  local  irritation  prodvices 
peritonitis,  by  interstitial  cell  proliferation  it  produces  venous  compression 
and  serous  effusion,  and,  by  arterial  obstruction, necrosis,rupture  of  vessels 
into  the  peritoneum,  and  thus  increased  temperature.  The  advance  of  the 
growth  into  adjacent  organs,  as  into  the  rectum  or  intestines,  by  narrow- 
ing them,  may  produce  obstruction ;  and  subsequently,  with  or  without 
obstruction  of  them  or  of  the  bladder,  necrosis  of  the  cancerous  structure 
may  occur,  and  the  contents  of  the  viscus  may  be  discharged  through  an 
open  sloughing  hole.  Further  extension  through  the  lymphatics  and 
veins  effects  the  transference  of  malignant  cells  to  other  more  distant 
organs,  which  there  become  the  foci  of  fresh  similar  growths;  thus  by 
continuous  excessive  cell  proliferation,  necrosis,  septic  absorption,  haem- 
orrhage, serous  discharge  and  pain,  the  system  is  finally  exhausted. 

II.  The  conditions  too  often  incident  to  the  education  of  the  mind 
may  materially  and  injuriously  affect  the  physicjue  of  women  in  civilised 
life.  For  six,  eight,  or  more  hours  a  day  during  eight  or  nine  months  in 
the  year,  the  girl  is  in  a  room  indoors  where  are  many  others,  so  that  the 
air  is  frequently  impure.  The  arms  and  legs  are  at  rest,  and  in  cold 
weather  are  chilled  and  the  circulation  iinyjoded,  so  that  chill)]ains,  even 
where  there  are  no  frosts,  are  common.  The  stooping  posture  over  desk 
or  bof>k,  in  drawing  or  at  the  piano,  produces  one  general  curve  of  the 
vertebral  column  instead  of  the  normal  three  upper  compensating  smaller 
curves ;  and  frequently,  by  fatigue,  weariness,  or  defective  eyesight,  some 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     135 

lateral  curvature  is  established.  There  is  an  increased  attraction  of 
Ijlood  to  the  brain,  and  great  call  upon  the  mental  powers.  Exercise  is 
neglected,  and  may  consist  of  a  constitutional  walk  in  pairs,  a  mode  which 
is  foreign  to  the  natural  habits  of  young  people;  thus  there  is  long 
physical  repose  and  merely  formal  exercise  at  an  age  of  naturally  almost 
constant,  free,  untrammelled  play  and  muscular  activity.  Personal 
competition,  culminating  in  place  examinations,  may  favour  the  egoistic 
temperament  instead  of  the  altruistic,  instead,  that  is,  of  the  care  for 
others,  as  of  the  next  generation,  which  normally  is  a  strong  feminine 
characteristic.  In  large  public  schools  for  both  sexes  the  close  associa- 
tion of  young  people  may  induce  an  injurious  sexual  knowledge  and 
desire,  conscious  or  unconscious,  without  the  opportunity  of  lawful  or 
moral  satisfaction. 

But  the  individual  type  must  dominate  all  such  educational  habits, 
however  it  may  be  thereby  modified ;  and  it  must  always  be  remembered 
that  the  strongest  instinct  in  woman  is  the  sexual  —  not  necessarily  the 
sexual  appetite,  but  the  production  of  the  next  generation ;  thus  there 
may  be  strong  or  feeble  sexual  development  with  a  feeble  or  strong 
l)hysique  ;  in  either  case  with  high  or  only  moderate  mental  attainment. 

The  general  effect  of  the  educational  course  then  may  be  to  develop 
mental  at  the  expense  of  physical  power,  and  especially  of  the  muscular 
power,  and  the  strength  of  the  vertebral  column  ;  by  diminished  demand 
on  the  elements  of  nutrition,  to  reduce  the  appetite  and  the  powers  of 
digestion,  and  thus  the  quality  of  the  blood ;  and  to  favour  constipa- 
tion, feecal  absorption,  ansemia,  and  irritable  and  hypersensitive  nerves. 
The  important  function  of  menstruation  is  thus  readily  deranged ; 
and  irregularities,  such  as  menorrhagia  by  deficiency  of  coagulation,  or 
of  strength  of  the  veins  in  the  strongly  sexually  formed,  or  amenorrhoea 
in  feebly  developed  sexual  organs,  arise ;  and,  if  the  mind  be  of  the 
artistic  or  aesthetic  kind  and  non-passionate,  the  sexual  organs  fall  in  some 
degree  into  abeyance,  and  may  subsequently  remain  feeble ;  there  may  be 
disgust  at  marital  rites,  and  a  tendency  to  hereditary  sexual  degeneration. 

III.  Personal  Habits. — There  is  no  such  care  taken  by  us  at  the 
menstrual  epochs  as  among  some  other  races,  where  the  women  seclude 
themselves,  so  that  the  function  is  quietly  performed.  With  iis  it  is  not 
unusual  for  a  woman  to  inject  cold  water  or  to  take  a  cold  bath  to  stop 
the  flow  for  social  or  sexual  purposes.  The  feet,  clad  in  thin  shoes,  often 
become  damp  and  remain  so,  and  in  cold  seasons  are  habituall}'  chilled 
through  the  soles.  The  evaporation  of  perspiration  in  cotton  under- 
clothing abstracts  much  heat  from  the  body  and  chills  it,  and  the  legs 
are  but  little  protected  from  cold  Avinds. 

Any  of  the  above  causes  may  produce  contractions  of  the  superficial 
vessels,  Avith  engorgement  of  the  deeper,  thus  throwing  on  the  latter  the 
necessity  of  reactionary  contraction,  which  they  may  be  unable  to  per- 
form. An  unequal  state  of  blood-supply  thus  occurs  in  the  body,  and 
the  defending  army  of  phagocytes  and  leucocytes  may  be  unable  suc- 
cessfully to  combat  attacking  bacilli,  whose  victory  is  proclaimed  in  the 


136  SYSTEM  OF  GYNECOLOGY 

statement  that  a  cold  tias  been  taken,  a  cold  which  may  be  the  beginning 
or  further  baeillar}"  successes  in  this  enfeebled  condition.  Or  the  deeper 
vessels  may  be  unable  to  bear  the  undue  strain  of  such  engorgement,  and 
their  coats  yield,  producing  haemorrhage  or  ht'ematocele ;  or  again,  irregular 
contraction  of  muscular  fibres,  as  of  the  Fallopian  tubes,  may  occur,  so 
that  their  secretions,  mucous  or  menstrual,  may  effuse  from  the  fimbrice, 
and  peritonitis  result  —  in  this  case  probably  in  connection  Avith  some 
lower  uterine  stenosis. 

In  the  case  of  vaginal  injection  of  cold  or  very  hot  water  dui'ing 
menstruation  a  similar  local  vascular  contraction  may  be  induced  without 
subsequent  reaction,  and  the  flow  may  cease ;  this  sudden  shock  may 
subsequently  induce  such  a  local  depression  of  the  circulation  that  the 
ovic  maturation  and  catamenial  discharge  may  cease  for  a  long  period, 
and  the  system  suffer  from  the  local  anaemia  and  functional  arrest. 

But  of  all  injurious  influences  to  woman,  to  which  is  attributable  the 
great  mass  of  the  disease  now  so  prevalent,  is  the  extraordinary  custom 
of  the  alteration  of  the  form  of  the  body,  and  of  the  position  and  rela- 
tions of  the  internal  organs,  by  the  almost  universal  custom  of  compression 
of  the  lower  thorax  and  abdomen;  were  this  done  to  animals,  we  should 
recognise  its  amazing  injury  and  absurdity.  The  busk  is  a  very  powerful 
lever  —  the  power  of  which  woman  does  not  understand ;  by  it  she  always 
compresses  her  body  from  1  to  3  inches  ;  and  frequently,  especially  when 
stout,  and  therefore  more  subject  to  the  injurious  influences  of  com- 
pression, 4  to  6  inches.  The  dress  is  similarly  tight,  and  usually  cannot 
be  fastened  unless  the  stays  have  effected  previous  compression. 

The  influence  is  markedly  accentuated  by  the  attachment  of  the 
skirts  and  petticoats  around  the  waist  and  abdomen  which  have  to 
support  them.  These  usually  weigh  fi'om  four  to  six  or  eight  pounds, 
and  react  especially  on  the  organs  of  the  abdomen  and  pelvis. 

Such  compression  affects  the  muscles,  and  invariably  displaces  the 
organs  of  the  body  to  an  extent  proportionate  to  the  degree  of  pressure. 

The  traction  force  required  to  approximate  the  busks  in  a  natural 
separation  of  from 

1  to  2  inches  is  from    8  to  20  lbs. 


2  to  3      „ 

,,      20  to  40 

3  to  4      „ 

,,      40  to  GO 

4  to  5      ,, 

,,      60  to  80 

5  to  6      „ 

,,      70  to  90 

I  am  informed  that  the  compression  thus  exerted  on  the  body  is 
represented  by  half  these  weights.  Thus  a  woman  who  draws  in  her 
stays  from  3  to  4  inches,  a  very  common  custom,  places  herself  under 
a  direct  pressure  of  from  twenty  to  thii'ty  pounds  weight.  P)Ut  this  does 
not  allow  for  the  extra  pressure  produced  in  di-awing  a  deep  breath, 
when  the  approximated  busks,  under  even  the  heaviest  of  the  above 
weights,  will  readily  part  from  half  an  inch  to  an  inch.  This,  however, 
is  impossible  when  the  busks  are  fastened,  and  this  additional  pressure 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     137 

also  is  therefore  exerted  directly  downwards  on  the  pelvic  organs.  There 
is  additional  increase  of  pressure  by  the  weight  of  the  skirts  and  petti- 
coats, and  by  food  or  liquid  taken  into  the  stomach  ;  when  intestinal  gas 
forms  from  induced  indigestion,  the  condition  is  thereby  accentuated. 

The  spinal  column  is  placed  in  splints  upon  which  it  tends  to  rely, 
and  its  movements  are  limited ;  the  muscles,  therefore,  atrophy  by 
deficient  use,  so  that  the  woman  says  her  back  would  break  if  she  did 
not  wear  them.  By  the  bending  of  the  back  in  her  education,  and  the 
wasting  of  the  muscles  by  the  wearing  of  stays,  the  normal  curves  of  the 
spine  are  frequently  lost  and  abnormal  curvatures  induced.  The  general 
strength  of  the  body  is  thus  reduced.  Similarly,  the  pressure  on  the 
abdomen  forces  down  the  intestines,  stretches  the  lower  abdominal 
wall,  and  renders  its  muscles  atrophic ;  hence  an  important  reduction 
of  reflex  and  voluntary  muscular  power  in  labour.  The  compression  of 
the  lower  ribs  forces  up  the  diaphragm,  squeezes  the  lungs,  and  dis- 
places the  heart,  so  that  fainting  from  this  cause  is  not  uncommon.  The 
kidneys  are  affected  proportionately  to  the  degree  in  which  the  lower 
ribs  approach  the  iliac  crest.  If  the  ribs  be  high,  their  indentation  on  the 
upper  half  of  the  kidney  displaces  it  downwards,  stretching  the  connective 
tissue  which  attaches  it  in  its  bed  of  fat;  it  is  then  said  to  be  movable; 
and,  from  the  variable  pressures  to  which  it  is  subjected  in  the  wearing 
and  non-wearing  of  the  stays,  it  is  apt  to  be  painful :  the  right  kidney, 
being  usually  the  lower,  is  most  frequently  thus  displaced.  The  liver 
is  flattened  by  the  ribs,  perhaps  indented  by  their  edges,  and  often 
extends  to  the  level  of  the  umbilicus ;  the  bile  ducts  are  compressed, 
and  constipation  and,  occasionally,  jaundice  result.  The  stomach  is  so 
squeezed  that,  when  food  is  taken  after  the  stays  have  been  put  on, 
there  is  no  opportunity  for  its  normal  enlargement  thereby,  nor  for  the 
long  process  of  churning  essential  to  normal  digestion ;  thus  the  food  is 
passed  on  into  the  intestines  in  a  partially  digested  form ;  dyspepsia 
follows,  and  a  tendency  to  ulcer  of  the  stomach  by  vascular  stasis  due 
to  the  long-continued  pressure.  The  small  intestines  are  depressed,  and 
receive  the  ingesta  in  an  abnormal  state ;  so  that  putrefactive  changes 
occur  in  them,  which  produce  flatulence  and  distension ;  compression 
about  the  ilio-caecal  valve  infliiences  appendicitis.  The  transverse 
colon  is  forced  downwards,  tending  to  produce  obstructing  angles  at  its 
junction  with  the  ascending  and  descending  portions,  which  are  depressed ; 
and  thus  impairment  of  the  peristaltic  movements,  flatulence,  and  con- 
stipation ensue.  The  rectum  is  compressed  by  the  pelvic  contents,  so 
that  the  faeces  tend  to  be  unduly  retained.  Thus  it  comes  about  that 
digestion  is  impaired,  flatidonce  arises,  constipation  is  produced,  the 
moisture  of  the  fiBces  is  absorbed,  the  blood  is  depreciated  in  quality  and 
rendered  impure,  nutrition  of  the  body  falls,  and  the  muscular  force  is 
reduced ;  the  teeth  become  carious,  which  reacts  on  the  digestive  func- 
tions; the  nerves  are  debilitated,  and  neuralgias  ensue;  menstruation 
is  disordered,  and  the  general  evils  of  anaemia  result ;  the  capacity  of 
the  bladder  is  reduced,  rendering  micturition  frequent,  and  subsequently 


SYSTEM   OF  GYNAECOLOGY 


often  painful  and  necessitous.  If  the  uterus  be  strong,  and  tlie  bladder 
not  subject  to  much  distension,  relieved  perhaps  by  frequent  micturition 
set  up  by  cr6"n'ding  of  the  parts,  the  pressure  of  the  intestines  forces  its 
body  forwards  and  downwards  into  a  horizontal  position,  and  the  cer- 
vix is  apt  to  follow  the  anterior  course  of  the  body,  the  whole  organ 
rotating  forwards  on  a  transverse  axis,  so  that  it  is  anteverted;  thus 
the  body  unduly  presses  on  the  bladder,  and  additionally  irritates  it,  Avliile 
the  face  of  the  cervix  is  subject  to  friction  on  movement  against  the 
posterior  vaginal  fornix,  when  there  is  aggravation  of  the  virginal  granular 
face,  previously  described,  and  degenerative  diseases  often  ensue.  Or, 
perhaps  by  rectal  accumidation,  the  cervix  is  pushed  forwards,  more 
often  into  the  perpendicular  position,  and  anteflexion  results.  If  the 
uterus  be  of  feeble  development  the  body  has  already  fallen  forwards ; 
but,  by  the  pressure,  the  condition  of  anteflexion  is  accentuated. 

Or  a  strongly  developed  uterus  may  be  unduly  retroposed  by  the 
flattening  from  above  of  the  bladder ;  the  forcing  down  of  intestines  into 
the  pelvis  tends  to  depress  it  into  a  lower  pelvic  plane,  and  the  usual 
retention  of  faeces  in  the  rectum  presses  the  cervix  forwards,  inducing 
a  rotation  of  the  strong  uterus  backwards  on  a  transverse  axis  at  the 
junction  of  the  cervix  with  the  body  ;  thus  the  retroversion  is  completed. 
The  virgin  uterus  rarely  proceeds  further,  because  of  the  strength  of  its 
posterior  wall;  but  in  the  parous,  if  subinvoluted  ligaments  and  connective 
tissue  permit  the  rotation  to  proceed,  the  uterine  body  may  descend  to  a 
much  lower  plane  of  the  pelvis,  so  that  the  fundus  presents  downwards 
and  backwards ;  and,  if  the  organ  be  of  strong  construction,  the  pelvis 
capacious  and  the  vaginal  structures  subinvoluted,  the  cervix  may 
maintain  its  normal  line  with  the  body  of  the  uterus,  and  the  os  present 
upwards  and  forwards  toward  the  anterior  vaginal  fornix  —  the  extremest 
possible  condition  of  retroversion. 

Or,  instead  of  the  continuance  of  the  normal  relative  continuity  of 
direction  of  the  body  and  cervix  of  the  organ,  from  its  subinvolution  and 
consecpaent  flabbiness  of  tissue  and  pelvic  resistance  to  the  rising  of  the 
cervix,  an  angle  of  flexion  at  the  cervico-corporeal  junction,  or  even 
somewhat  higher,  may  be  formed,  and  retroflexion  ensues,  the  body  being 
perhaps  horizontal  and  the  cervix  perpendicular.  A  further  stage  is  at- 
tained wlien  the  body  and  fundus  descend  lower,  so  that  the  body  and  cer- 
vix tend  to  l)ecome  parallel ;  this  is  the  more  induced  and  accentuated  by 
the  continued  abdominal  pressure  on  tlio  convexity  of  the  angle  of  flexion, 
so  that  their  impaction  in  the  pelvis  results  from  extreme  retroflexion. 

The  Fallopian  tubes  are  liable  to  be  bent  at  their  junction  with  the 
uterus  by  the  misplacement  of  the  uterus  in  combination  with  pressure 
downwards  of  the  intestines  by  the  stays  and  dress.  Thus  in  the  sexual 
engorgement  in  love-making,  with  or  without  union,  in  women  of  warm 
appetite,  this  abnormal  relation  of  the  tubes  to  the  uterus  may  induce 
efl"usion  of  their  secretions  into  the  peritoneum,  parti(!ularly  during 
menstruation,  and  a  local  peritonitis;  otlKU-wise,  they  would  pass  in  the 
normal  direction  through  the  genital  canal. 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     139 

The  ovaries  are  depressed,  and  forced  into  a  latero-posterior  position, 
carrying  the  fimbriae  with  them  by  the  attachment  of  tlie  tubo-ovarian 
fimbria.  Thus,  by  the  pressure  of  the  ovaries,  the  fimbriae  may  be 
flattened,  rendered  oedematous,  and  unable  to  apply  themselves  to  the 
Graafian  follicles ;  these  discharge  into  the  peritoneum,  and  may,  by  a 
valve-like  opening  occurring  from  the  compression,  produce  a  recurrent 
peritonitis  of  some  severity. 

In  pregnancy  the  stays  are  often  worn  very  tight  so  as  to  conceal 
the  condition ;  thus  miscarriages  and  premature  confinements  may  be 
brought  about  by  the  accentuation  of  the  normal  rhythmic  uterine  con- 
tractions, by  induced  dilatation  of  a  previously  lacerated  cervix,  or  by 
rupture  of  the  membranes.  By  pressure  on  the  abdominal  veins  by 
depression,  or  repression  on  the  vena  cava  of  the  pregnant  uterus,  vari- 
cose veins  are  induced,  the  legs  and  vulva  become  oedematous,  the  veins 
may  rupture,  and  vulvar  or  pelvic  haematocele  be  produced. 

The  pressure  on  the  foetus  may  alter  its  presentation ;  pressure  on 
the  uterus  may  enfeeble  its  structure,  as  well  as  that  of  the  accessory 
muscles  of  labour,  wdiich  may  be  thus  ineffective ;  forceps  are  now 
applied  in  the  women's  hospital  in  Melbourne  once  in  nine  confine- 
ments of  all  cases,  and  in  private  much  more  frequently. 

There  is  such  a  forcing  downwards  of  the  uterus  on  the  ligaments  as 
must  tend  to  stretch  them,  and  render  depression  of  the  uterus  to  a 
lower  pelvic  plane  and  axis  more  ready  after  labour,  leading  to  subin- 
volution, misplacements,  and  prolapse. 

Thus  by  the  wearing  of  tight  stays  the  whole  system  of  the  Avonuin 
is  enfeebled,  the  pelvic  sexual  organs  are  apt  to  be  misplaced,  and  the 
basis  is  laid  for  that  evolutionary  disease  and  sterility  which  are  now 
so  common. 

Another  mode  of  injury  by  compression  is  the  use  of  the  tight 
binder  after  labour.  No  doubt  that  a  very  firm  pressure  on  the  body  of 
the  uterus  is,  in  civilisation,  frequently  necessary  immediately  after  the 
end  of  the  third  stage,  in  order  to  prevent  or  stop  post-partum  luemor- 
rhage,  common  from  the  above-mentioned  causes ;  but  in  a  couple  of 
hours  after  the  cessation  of  the  haemorrhage  this  danger  is  past,  when 
binder  pressure  becomes  injurious  without  compensating  advantage. 

After  the  passage  of  the  child  the  walls  of  the  cervix  for  a  time 
commonly  lie  in  a  state  of  muscular  relaxation,  so  that  an  excessive 
abdominal  pressure  tends  to  evert  the  internal  cervical  or  endometrial 
structure  through  the  cervical  opening.  Very  much  more  is  this  the 
case  when  the  cervix  has  been  lacerated,  whereof  the  only  satisfactory 
mode  of  healing  is  by  first  intention ;  to  this  result  eversion  must  be 
fatal.  To  such  a  cause,  which  also  bends  the  uterine  veins,  is  often  due 
the  prolongation  of  the  red  lochia ;  and  by  the  irritation  of  tension  on 
the  angles  of  lacerations  deep  into  the  vaginal  junction,  an  inflamma- 
tion of  the  connective  tissue  of  the  broad  ligament  ensues,  which  might 
otherwise  have  healed  by  a  ]U'imarv  and  softer  union.  The  undue 
pressure,  too,  on  the  tubes  thus  cruslu-d  between  the  large  uterus  and 


I40  SYSTEM  OF  GYNECOLOGY 

the  pelvis  may  induce  au  effusion  from  tlie  linibriaj  which  may  cause  a 
peritonitis,  perhaps  of  mikl  character,  but  sufficient  to  induce  an  exuda- 
tion of  fibrin,  which  may  bind  down  the  appendages  and  uterus. 

The  ligaments  of  the  uterus  are  maintained  in  a  state  of  tension ;  the 
relation  of  the  veins,  which  are  of  great  size,  is  altered,  and  the  circulation 
through  them  to  some  extent  obstructed,  perhaps  inducing  thrombosis ; 
the  uterus  is  unduly  congested,  and  its  involution  impeded.  On  diminu- 
tion in  size  of  the  uterus,  so  that  it  regains  a  position  in  the  pelvis,  it  is 
still  large ;  the  subsequent  pressure  by  the  stays  and  the  perpendicular 
position  of  the  woman  depress  it  into  a  lower  plane  and  more  perpendicular 
axis  of  the  pelvis,  and  into  the  state  of  retroflexion,  as  previously  described. 
Thus  under  the  influence  of  a  continuous  tight  binder  and  subsequent 
tight  stays  the  condition  presently  found  may  be  one  of  deep  laceration 
with  everted  granular  faces,  perhaps  some  connective  cicatricial  thicken- 
ing in  one  or  other  broad  ligament,  subinvolution  and  retroflexion  of  the 
uterus,  perhaps  with  such  adhesions  as  bind  it  down.  Such  influence 
may  also  aft'ect  the  column  of  the  vagina  and  its  connective  tissue,  and 
extend  to  the  vulva  and  perineum,  rendering  them  also  subinvoluted. 

The  large  abdomen  of  the  parous  is  frequently  due  to  the  predisposing 
influences  of  the  unnatural  habits  before  mentioned,  which  create  a  dis- 
position to  undue  flatulent  distension  of  the  intestines;  this,  combined 
with  the  pressure  on  the  waist  by  the  petticoats  and  skirts,  farther 
forces  down  the  lax  abdominal  walls,  and  accentuates  the  gaseous  dis- 
tension. These  causes  are  aided  by  that  excessive  fat  in  the  abdominal 
walls  which  results  from  deficient  exercise  and  work. 

The  application  of  a  tight  binder  which  depresses  the  uterus  is  dis- 
tinct from  a  well-regulated  bandage  which  serves  normally  to  support 
the  abdominal  walls. 

The  conditions  present  to  those  who  give  themselves  to  the  life  of 
society  are  that  they  expose  their  necks  to  the  suddenly  varying  tem- 
peratures of  heated  ball-rooms,  corridors,  verandahs,  and  gardens ;  they 
wear  their  dresses  exceptionally  tight ;  healthy  exercise  is  usually  defi- 
cient, but  there  is  over-exertion ;  from  the  great  and  almost  constant 
excitement  there  are  undue  nerve  tension,  and,  not  seldom,  disappoint- 
ments ;  the  diet  is  irregular,  and  dainties  are  x)i'eferred ;  the  hours  are 
late ;  sleep  is  ii-regular,  and  taken  at  abnormal  hours  ;  repose  of  body 
and  mind  are  deficient. 

The  effects  are  apt  to  be  that  colds  are  taken,  and  are  with  difficulty 
shaken  off ;  the  appetite  is  impaired,  digestion  enfeebled,  and  constipation 
established;  the  formation  of  the  blood  is  injured,  anismia  and  general 
debility  ensue ;  the  catamenia  become  irregular ;  the  nerves  are  impov- 
erished, so  that  neuralgias  and  hysteria  arise,  and  the  weight  declines. 
Such  parous  women  are  apt  to  suffer  fi-om  subinvolution  with  endometi-itis 
and  its  consequences  for  reasons  pi'cviously  mentioiKHl ;  and  tlie  milk  is 
liable  to  be  deficient  in  fiuantity,  or  of  excessive  (juantity  and  of  feeble 
quality,  so  that  the  systems  of  l)oth  motlu!!-  and  (iliild  are  im])overished. 

The  diets  that  act  injuriously  are  the  defective  and  the  unlit.     It  is 


ETIOLOGY  OF  DISEASES    OF  FEMALE    GENITAL    ORGANS     141 

common  among  young  girls  of  delicate  constitution  and  temperament  to 
have  an  apparent  pleasure  in  refusing  plain  healthy  food,  or  a  necessary 
quantity  of  any  kind.  Thus  some  will  take  no  breakfast,  or  only  a  glass 
of  water ;  milk  and  meat  are  refused ;  and  this  refusal  appears  to  be- 
come a  point  of  honour.  Single  women  from  thirty-five  to  forty-five 
years  of  age,  and  women  upon  whom  is  a  great  drain  of  child-bearing 
and  lactation,  may  similarly  decline  animal  food. 

The  improper  diets  among  young  girls  may  include  eating  unripe 
fruits  in  place  of  ordinary  food ;  or  pastry,  cakes,  and  sweets  at  irregu- 
lar hours.  Older  women,  especially  in  warm  climates,  frequently  drink 
large  quantities  of  very  hot  strong  tea,  or  of  water.  All  such  aberrant 
diets  tend  to  dyspepsia,  flatulence,  constipation,  anaemia,  and  amenor- 
rhoea ;  and  in  the  parous  also  to  subinvolution  with  endometritis,  and 
their  consequences. 

IV.  The  influence  of  absence  of  marriage,  and  late  marriage,  which 
are  the  tendencies  of  our  age  ;  and  of  ineffective  marriage,  which  includes 
artificial  prevention  of  pregnancy,  are  highly  deleterious.  The  due  age  of 
marriage  certainly  varies  according  to  climate,  and  in  that  of  Great  Britain 
the  perfection  of  development  is  from  twenty-three  to  thirty  ;  but  at  the 
age  of  thirty  half  the  women  are  yet  unmarried,  so  that  about  half  of  the 
period  of  their  capacity  of  propagation  has  already  passed.  While  many 
women  in  civilised  communities  are  signally  deficient  in  sexnal  a})petite, 
many  are  normally  developed  in  this  respect.  Such  due  appetite  may  be 
strongly  present  in  girls  of  plain  features,  who  are  unattractive,  ill- 
nourished,  and  depressed ;  and  it  is  perhaps  particularly  in  these  that 
a  normal  temporary  congestion  and  unsatisfied  desire  lead  to  injurious 
habits  which  produce  chronic  congestion,  endometritis,  and  the  like. 

The  common  effect  on  the  physique  of  postponing  marriage  is  to  induce 
a  general  atrophy ;  the  fat,  which  imparts  the  rounded  outline  to  woman, 
falls  away  and  she  becomes  angular,  her  muscles  and  tendons  are  distinctly 
outlined,  and  markedly  noticealile  about  the  face  and  neck ;  the  quality 
of  the  blood  has  sutt'ered,  and  anaemia  may  have  resulted;  the  nutrition 
of  the  nerves  has  been  impoverished,  and  neuralgias  and  hysteria  are 
common ;  the  catamenia  may  have  become  irregular,  and  be  either  in- 
creased or  diminished  according  to  the  temperament ;  and  leucorrhoea 
may  have  resulted  from  desire  unsatisfied  by  marriage  or  pregnancy. 
Some  women  who  have  a  good  sexual  formation,  except  for  a  small 
external  uterine  opening  and  deficiency  of  sexual  appetite,  grow  fat,  the 
catamenia  decrease,  and  the  organs  atrophy  from  absence  of  employment. 

But  the  influence  of  the  normal  impulse  to  the  production  of  the 
next  generation  is  amply  demonstrated  in  sexually  well-developed  persons 
who  from  non-marriage  have  not  become  pregnant ;  or  who,  from  Avhatever 
cause,  have  ceased  for  a  long  time  to  bear  children ;  by  the  frequent  occur- 
rence in  such  persons  of  myoma  of  the  uterus :  in  myoma  the  muscular 
fibres  iiicrease  in  many  sites  in  an  irregular  manner,  which,  in  multi- 
])lication,  is  analogous  to  that  of  pregnancy;  indeed,  in  an  early  stage 
its  further  development  may  be  stopped  by  pregnancy,  for  the  uterus 


142  SYSTEM  OF  GYNAECOLOGY 

has  thus  been  employed   naturally,  and  its  nutrition   engaged  in  its 
proper  functions. 

V.  Sexual  Exhaustion. — Under  normal  circumstances  in  healthy 
women,  coitus,  though  at  first  on  marriage  liable  to  be  excessive,  is  usually 
limited  presently  by  custom,  and  pregnancy  ensues.  Some  husbands,  and 
some  women  also,  have  an  insatiable  sexual  appetite.  Thus  on  the  part 
of  the  man  the  act  may  be  repeated  very  frequently ;  or  the  woman  may 
be  subject  to  many  men,  as  are  prostitutes;  or  unnatural  habits  may  be 
adopted ;  or  pregnancy  may  be  avoided,  with  consequent  absence  of 
satisfaction,  and  thus  of  relaxation.  All  these  conditions  are  liable 
to  cause  a  chronic  congestion,  resulting  in  endometritis  ;  or,  in  case  of 
pregnancy,  in  miscarriage  or  premature  confinement  Avith  succeeding 
subinvolution  and  endometritis :  the  induction  of  miscarriage,  which  is 
now  so  common,  has  the  same  effects.  The  frequent  strain  produces 
debility,  and  the  nervous  system  is  weakened. 

Regular  child-bearing  with  a  normal  condition  of  the  uterus  and 
moderate  lactation  seldom  injures  the  woman  ;  but  when,  combined  with 
granular  cervix  and  endometritis,  the  system  is  debilitated  by  the  undue 
drain  of  excessive  cell  formation,  disease  is  apt  to  ensue. 

The  child-bearing  which  would  be  healthily  effected  in  a  temperate 
climate  is  excessive  to  the  British  race  in  tropical  countries,  in  which 
the  blood  becomes  thinner  and  the  vessels  dilated  ;  then  post-partum 
haemorrhage,  subinvolution,  endometritis,  menorrhagia  and  anaemia  are 
common. 

The  congestive  thickening  of  the  vaginal  membrane  near  its  poste- 
rior commissure  from  excessive  coition  may  produce  occlusion  or  steno- 
sis of  one  or  other  vulvo-vaginal  duct ;  the  secretion  accumulating  in 
the  more  dilated  part  near  the  gland  may  continue  clear,  and  a  cyst  be 
formed;  or,  if  septic  germs  gain  admission  by  tlie  duct  or  tlirough  the 
blood,  suppuration  occurs. 

VI.  Infectious  Diseases.  —  Syphilis  is  said  not  to  be  conveyed  to  the 
foetus  through  the  placenta,  but  through  the  germ  or  sperm.  The  foetus 
is  liable  to  be  affected  in  the  congenital  form  when  one  or  both  of  the 
parents  is  actively  diseased  in  the  second  stage  at  the  time  of  impregna- 
tion; after  conception  the  father,  who  nuiy  have  been  free  from  symptoms 
for  many  months,  may  suffer  froni  a  syphilitic  testicle,  or  the  mother 
from  a  rash  ;  or,  after  a  period  of  apparent  health  for  perhaps  twenty  or 
thirty  years,  a  parent  may  have  a  specific  rash.  The  degree  to  which 
the  progeny  is  liable  to  be  affected  is  in  proportion  to  the  virulence, 
attenuation,  or  quiescence  of  the  parental  disease. 

The  effects  are  seen  in  hereditary  congenital  and  simple  forms.  In 
the  former,  malformations,  from  inflammatory  arr(!st  or  deficieuces  of 
dcvehjpmcnt,  are  present  at  birth,  l)f'ing  induced  by  a,u  inflaiiimatoiy 
action  in  the  cells,  ducts,  or  vessels,  destroying  or  closing  them,  and 
arresting  development.  In  the  latter  the  results,  similarly  caused,  may 
not  manifest  themselves  for  varying  periods  after  birth. 

The  mother  may,  however,  directly  transmit  measles,  scarlatina,  and 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     143 

small-pox  to  the  foetus,  perhaps  through  the  liquor  amnii,  and  the  same 
results  ensue  (Hamilton). 

Syphilis,  by  irritation  of  its  secretions,  produces  condylomata  about 
the  vulva  and  anus,  and  enlargement  of  the  inguinal  glands,  with  the 
consecutive  affections. 

The  inflammation  of  mucous  membranes,  accompanying  such  dis- 
eases as  scarlatina  and  measles  in  which  micrococci  have  been  found, 
may  attack  the  vagina,  uterus,  and  tubes ;  and,  since  the  outlets  are  of 
small  size  during  childhood,  it  may  continue  in  a  chronic  form,  and 
lead  to  evolutionary  affections  of  the  peritoneum  and  ovaries. 

To  gonorrhoea  is  to  be  ascribed  a  series  of  progressive  diseases,  which 
are  liable  to  be  as  virulent  as  they  are  continuous. 

Miserable  to  relate,  this  disease  is  met  with  even  among  little  girls. 

A  young  girl  may,  primarily,  take  it  from  a  man  Avho  had  the  idea  that 
his  gonorrhoea  was  curable  by  contact  of  a  young  virgin ;  and  she  may 
convey  it  to  others  by  the  fingers.  It  may  possibly  be  contracted  by 
other  means,  as  by  contact  of  the  vulva  with  gonorrhoea-infected  towels, 
closet-seats,  or  chamber  utensils ;  but,  whatever  the  sex  or  age  of  the 
patient,  there  has  been  direct  contact  with,  the  discharge  of  a  previously 
diseased  person.  These  young  girls,  perhaps  but  of  a  few  years  of  age, 
may  retain  the  disease  for  many  months  or  even  years,  during  which  it  is 
liable  to  advance  into  the  higher  genital  organs,  and  produce  evolutionary 
results.  In  this  way  it  may  be  a  common  cause  of  the  peritonitis  of 
female  childhood,  and  of  adhesion  and  arrest  of  development  of  the  genital 
organs,  perhaps  with  their  displacement;  of  the  latter  results,  a  small 
adherent  retroverted  uterus  and  adherent  atrophic  ovaries  may  be  sub- 
sequently apparent  as  having  occurred  during  the  years  of  childhood. 

The  vagina  is,  primarily,  not  readily  subject  to  the  affection,  an  im- 
munity probably  due  to  the  absence  of  glands  in  which  the  microbe  may 
find  a  nidus.  Thus  the  gonococcus  at  first  finds  a  habitation  in  the  mucous 
follicles  at  the  orifice  of  the  urethra  or  vagina,  or  in  the  sinuosities  of  the 
uterine  cervical  glands.  When  thus  affecting  the  urethra  an  irritation 
arises,  which  induces  a  cell  proliferation  suitable  for  successful  attack  by 
streptococcus  and  staphylococcus  present  in  the  infecting  matter:  thus 
suppuration  results,  which,  in  combination  with  the  gonococcus,  travels 
up  the  urethra  to  the  bladder ;  hence  follows  cystitis.  Should  entrance 
to  the  ureters  be  effected  their  inflammation  ensues  ;  and  by  subsequent 
contraction  in  healing,  their  stricture  and  hydro-nephrosis.  If  progres- 
sive to  the  kidneys,  their  inflammation,  and  perhaps  suppuration,  leads 
to  pyonephrosis. 

Also,  the  canals  of  the  vulvo-vaginal  glands  may  likewise  be  pi-imarily 
affected  by  the  gonorrhoeal  infecting  matter,  and  abscess  in  them  occur. 
The  vagina  is  thus  continuously  exposed  to  the  disease,  and  becomes 
infected;  and  presently,  especially  if  the  os  uteri  gape,  the  cervical 
canal. 

Or  the  gonorrhoeal  matter  may.  in  union,  be  directly  injected  into  the 
canal  of  the  cervix,  and  take  up  a  habitation  in  the  gland-ducts ;  and  the 


144  SYSTEM  OF  GYNAECOLOGY 

vagina  be  secondarily  infected  by  the  downward  passage  of  thus  diseased 
secretions.  ,From  the  cervix  the  corporeal  endometrium  is  affected,  and 
the  micrococci  may  infest  the  sinuosities  of  its  gland-tubes.  Thus, 
should  the  vagina,  vulva,  and  urinary  canal  have  recovered  from  the 
disease,  perhaps  by  treatment,  a  later  downward  passage  of  the  gono- 
cocci  may  again  infect  the  vagina ;  hence  vaginal  recurrence. 

The  trumpet-mouth  of  the  Fallopian  tubes  renders  it  easy  for  the 
germs  to  enter  and  infect  them :  hence  salpingitis,  and  the  evolutionary 
affections  of  the  peritoneum  and  ovaries  described  in  detail  in  section  1. 

When  the  fimbria  of  a  tube  infected  by  gonorrhoea,  puerperal  septi- 
caemia, or  tuberculosis  is  adherent  to  an  ovary  of  which  a  Graafian  follicle 
ripens  and  bursts  into  it,  the  bacteria  enter  the  follicle  and  suppuration 
ensues  therein ;  or  when  an  accumulation  of  pus  occurs  in  the  fimbria 
adherent  to  the  inflamed,  distended,  thin  membrane  of  a  follicular  cyst, 
the  bacteria  may  enter  it  by  transudation.  Septic  pus  having  formed  in 
a  sac  of  an  ovary,  similar  abscesses  occur  in  other  follicles,  probably  by 
transudation  of  bacteria  under  similar  conditions ;  so  that  abscess  of  the 
ovary  is  usually  multiple,  though  the  septa  between  pus-sacs  may  break 
down  and  one  large  abscess  predominate  over  the  others,  and  the  ovary 
becomes  of  considerable  size. 

On  increase  of  pus  the  tunic  yields  in  the  direction  of  least  resistance  ; 
and,  as  in  pyosalpinx,  on  minute  rupture  peritonitis  results,  causing 
cohesion  of  the  ovary  with  adjacent  peritoneum,  if  this  had  not  taken 
place  previously.  Should  the  attachment  be  to  the  intestine,  the  pus  of 
the  rupturing  sac  escapes  into  it ;  but  the  other  sacs  of  the  multilocular 
abscess  do  not  thus  discharge  their  contents,  and  the  inflammatory  con- 
dition continues.  The  cause  of  abscess  of  one  ovary  may  also  apply 
to  the  other,  and  thus  both  may  suppurate  ;  and,  since  the  tubes  were 
previously  similarly  affected,  double  pyosalpinx  is  probably  also  pres- 
ent :  ovarian  suppuration,  however,  being  dependent  on  rare  relations 
and  opportunities,  seldom  occurs. 

Septicaemia  is  a  term  applied  to  a  class  of  diseases  induced  primarily 
by  the  entrance  of  putrefactive  liquids  into  the  systenl  through  the  blood- 
vessels or  lymphatics  :  different  parasitic  micro-organisms  in  these  liquids 
attack  and  overcome  the  defending  army  of  phagocytes  and  leucocytes, 
live  upon  the  blood,  and  secrete  a  toxine  or  poisonous  miasm  which 
may  be  fatal ;  these  events  may  arise  in  the  puerperal  state,  or  from 
accident  or  operative  causation. 

In  the  puerperal,  accidental,  or  operative  state  the  site  of  attack  is 
some  laceration,  wound,  or  injury;  as  of  the  perineum,  vagina,  cervix, 
uterus,  or  unclosed  venous  sinuses  or  lymphatic  vessels  of  the  ovic  or 
placental  site,  generally  l)y  retention  within  the  cavity  of  the  uterus  of 
portions  of  placenta,  perhaps  of  adherent  membranes  or  of  blood-clots. 
In  the  absence  of  the  use  of  antiseptics,  micro-organisms  may  success- 
fully attack  the  raw  tissues,  and  in  this  state  of  endosmosis  affect  the 
system.  They  are  particularly  infectious  in  the  state  of  comparative 
emptiness  of  the  vessels  caused  by  the  coincident  haemorrhage ;    but 


ETIOLOGY   OF  DISEASES    OF  FEMALE    GENITAL    ORGANS     145 

when  the  part  is  granulating  such  absorption  does  not  occur,  the  ves- 
sels are  in  a  state  of  fulness  and  tension,  and  the  tendency  is  towards 
exosmosis  in  relation  to  the  growing  of  new  tissue. 

The  attack  is  through  the  veins  or  the  lymphatics,  perhaps  through 
lymphoid  cells,  by  the  open  mouths  of  which  canals  these  micro-organ- 
isms may  enter.  In  the  former  case  septic  phlebitis  results,  in  which  the 
inflammation  is  proportionate  to  the  quantitj'  and  quality  of  the  sepsis. 
Thus,  if  the  cause  be  virulent,  the  tunica  interna  becomes  suppurative, 
and  the  progress  of  the  septic  germs,  rapidly  spreading  towards  the 
heart,  may  be  at  intervals  temporarily  checked  by  the  formation  of 
thrombi.  These,  however,  are  speedily  similarly  aliected,  they  disinte- 
grate, become  loose  in  the  enlarging  lumen  of  the  veins,  and  form  the 
nidus  of  fresh  infection  which  permeates  the  body  and  especially  affects 
synovial  membranes  ;  death  is  the  result.  If  the  sepsis  be  less  virulent, 
the  thrombi  may  maintain  a  firmer  attachment  to  the  venous  inner  walls, 
but  are  liable  to  become  loose  and  block  the  heart,  or  form  the  nucleus 
therein  of  larger  coagulations ;  or  they  may  form  infarctions  in  the  lungs, 
producing  pleuro-pneumonia ;  or  clotting  may  advance  toward  the  heart 
by  gradual  vein-wall  infection,  so  that  thrombosis  may  extend  from  the 
uterus  along  the  uterine  and  ovarian  and,  on  the  left  side,  the  renal 
veins ;  and  perhaps  on  both  sides  it  may  extend  into  the  vena  cava,  and 
thence,  on  the  right  side,  perhaps  infect  the  right  renal  vein.  Or  per- 
haps in  only  one  vein  in  the  broad  ligament  a  septic  thrombus,  guarded 
toward  the  heart  by  a  sufficiently  healthy  adherent  clot,  may  suppurate, 
burst  through  the  venous  coats,  infect  the  connective  tissue,  and  pro- 
duce a  pelvic  cellulitis,  discharging  in  the  direction  of  least  resistance. 

Should  a  virulent  septic  absorption  take  place,  especially  through 
lymphatic  vessels,  the  blood  may  at  once  be  so  affected,  probably  by 
secretion  of  bacterial  toxine,  that  it  becomes  disorganised,  and  death 
results  from  general  acute  septicaemia.  A  less  virulence  gives  time  to 
permit  se})tic  inflammation  of  special  structures,  as  of  serous  or  mucous 
membranes  ;  or  a  local  suppuration  from  septic  retention  in  a  lymphatic 
gland  in  a  broad  ligament  forming  suppurative  cellulitis ;  or,  in  a  less 
septic  degree,  resulting  in  inflammatory  induration  and  resolution. 

The  common  cause  of  puerperal  peritonitis  is  the  effusion  of  septic 
fluid  from  the  fimbria  infected  by  continuity  from  the  uterine  cavity. 
Thus  the  slight  primary  oozing  may  cause  a  peritonitis,  inducing  fibri- 
nous exudation  Avhich  occludes  the  fimbria  by  adhesion.  Should  the 
quantity  of  fimbrial  effusion  be  greater  the  peritonitis  is  stronger.  If 
the  quality  be  virulent  and  the  quantity  large,  the  fimbrial  effusion 
being  continuous  or  recurrent,  the  peritonitic  exudation  is  sero-purulent ; 
such  adhesion  as  occurs  is  feeble  and  ineffective  for  occlusion,  and  the 
peritonitis  is  general  and  virulent. 

Or,  less  frequently,  it  may  be  caused  \)j  the  ru]')turo.  bv  pressure 
of  the  child,  of  a  septic  sup]nirative  salpingitis  into  the  abdominal 
cavity;  or  such  a  tube  may  thus  burst  into  the  connective  tissue  of 
the  broad  ligament,  i)roducing  a  virulent  jielvie  cellulitis. 


146  SYSTEM   OF  GYiW-ECOLOGY 

Tuberculosis  iu  the  genital  organs  may  occur  either  by  the  arrival 
of  the  tubercle  bacillus  by  the  intestines,  by  the  blood,  or  through  the 
vagina.  If  "by  the  intestines,  the  bacilli,  probably  swallowed  in  tuber- 
cular pulmonary  sputum,  have  penetrated  the  intestinal  glands,  infected 
the  peritoneum,  and  thence  entered  the  fimbria  and  attacked  the  tube, 
and  perhaps  spread  to  lower  parts  of  the  genital  canal.  Coincidently 
the  more  distant  peritoneal  surface,  and,  by  deeper  attacks,  the  under- 
lying structures  of  the  ovaries,  tubes,  uterus,  and  broad  ligaments,  may 
be  aifected.  And  a  nidus  in  the  genital  organs  having  thus  occurred, 
farther  advance  into  the  heart  and  lungs,  perhaps  through  the  bron- 
chial glands  through  the  medium  of  wandering  lymphoid  cells,  may 
be  effected.  Secondarily,  tubercular  pus  may  escape  from  the  tube 
through  the  fimbria,  and  reinfect  the  peritoneum. 

Or  the  bacilli,  derived  from  swallowed  tubercular  pulmonary  sputum 
or  tubercular  ulcerating  intestinal  glands,  may  be  detained  in  the  lower 
rectum  in  constipated  or  liquid  faeces ;  and  successfully  attacking  the 
lymphoid  cells,  may  enter  lymph  glands,  induce  sxippuration  around  the 
anus,  and  produce  rectal  fistula.  Thence  by  progressive  lymph-gland 
disease,  the  connective  tissue  of  the  broad  ligament  may  be  attacked,  and, 
by  suppurative  destruction,  the  peritoneum  and  adjacent  genital  organs. 

By  the  blood  bacilli,  escaping  from  a  softening  pulmonary  tubercle, 
may  travel  in  the  current  until  they  arrive  at  a  capillary  in  the  genital 
organs,  where  they  may  conquer  a  lymphoid  cell  and  develop  a  tuber- 
cle,—  perhaps  in  a  lymph  gland  in  the  broad  ligament,  producing  tu- 
bercular pelvic  cellulitis. 

By  the  vagina  bacilli  may  gain  entrance  from  an  adjacent  rectal  tu- 
bercular fistula,  or  other  tubercular  suppuration  of  which  a  sinus  may 
perhaps  open  into  the  vagina,  and  the  bacilli  travel  upwards.  Or  the 
sperm  may  contain  bacilli,  which  advance  and  infect.  Or  the  discharge 
of  a  suppurating  tubercular  gland,  perhaps  submaxillary,  may  be  con- 
veyed by  the  finger  of  the  woman  within  her  vaginal  orifice.  The  ba- 
cillus, having  gained  entrance,  is  attacked  by  a  wandering  lymphoid 
cell,  which  it  may  conquer ;  and  thus  a  second,  gaining  nutrition  from 
the  tissue  of  these  cells,  may  enter  a  lymph-gland  and  produce  tuber- 
cle, which  may  suppurate  and  break  down.  Should  the  bacilli  be  very 
numerous  and  powerful,  a  general  infection  of  adjacent  structures  and 
infection  of  cardiac  proximal  glands  ensues,  and  the  disease  has  exten- 
sive foci.  F>iit  if  the  bacilli  be  but  of  moderate  vigour,  a  strong  fibroid 
sac  wall  of  condensed  connective  tissue  is  formed  about  the  al)scess,  and 
permeation  of  bacilli  is  effectually  resisted.  Thus  a  tu])ercular  abscess 
in  the  broad  ligament  may  be  coincident  with  a  suppurating  submaxil- 
lary gland  without  farther  extension ;  but  a  foetid  bacillus  may  have 
infected  the  pus. 

When  by  uncleanliness,  or  the  passage  of  urinary  crystals  or  sugar, 
or  of  small  worms  from  the  rectum,  a  vulvar  or  vaginal  irritation  has 
been  caused,  micrococci,  as  staphylococcus  and  streptococcus,  finding 
suitable  nutrition,  may  enter  the  vagina  and  induce  an  inflammatory 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     147 

state  called  vaginitis,  causing  pruritus  of  the  vulva.  This  occurs  the 
more  readily  if  the  hymen  be  contracted,  so  that  the  secretions  are 
retained ;  or  under  the  influence  of  the  venous  engorgeinent  of  pregnancy. 

Hydatid  tumours,  which  are  of  the  animal  kingdom,  may  have  a 
situation  in  the  wall  of  the  uterus,  ovary,  tube,  peritoneum,  OT  connective 
tissue  [y/cZe article  ''  Hydatids  "  in  Sijst.  ofMed.\  The  sexual  organs  arc 
displaced  according  to  the  size  and  direction  of  growth  of  the  timiour. 
By  rupture  or  puncture  dissemination  of  the  fluid  and  of  daughter  cysts 
is  effected ;  and,  if  into  the  peritoneum,  fibrinous  exudation  produces 
adhesions  which  may  bind  down  the  whole  tumour  to  adjacent  structures, 
or,  being  highly  vascular,  may  resemble  a  skein  of  scarlet  floss-silk  ;  or, 
by  continuous  escape  of  necrosed  contents,  may  set  up  a  progressive 
and  virulent  peritonitis. 

VII.  Accidental  and  operative. 

Accident,  Avhich  is  here  used  to  mean  the  unusual  effect  of  a  known 
cause,  is  the  common  cause  of  vaginismus,  which  is  the  spasmodic  con- 
traction of  the  muscles  about  the  orifice  of  the  vagina,  producing 
dyspareunia.  When  the  hymen  is  lacerated  in  union,  its  segments  re- 
tract to  the  vaginal  opening  at  various  sites  according  to  its  formation  ; 
but  most  generally  towards  the  posterior  commissure.  Subsequent 
frequent  union  and  irritation  may  prevent  the  healing  growth  of  epi- 
thelium over  the  raw  edges,  which,  becoming  inflamed,  develop  hyper- 
vascular  and  hypersensitive  papillae.  Their  continued  irritation  by 
attempted  union,  by  the  friction  of  walking,  or  by  the  constant  bathing 
of  their  surfaces  in  the  acid  vaginal  secretion,  may  maintain  the  condition. 
Any  attempt  to  enter  the  vagina  produces  a  reflex  contraction  of  the 
muscles  which  close  the  opening,  as  of  the  bulbo-cavernosus  muscle,  and  of 
the  adductors  of  the  thighs,  as  Avell  as  a  retraction  of  the  pelvis  from  the 
source  of  the  pain.  The  same  effect  results  from  a  similarly  produced 
non-healing  tear  of  the  posterior  commissure,  causing  a  fissure ;  from 
the  intense  sensitiveness  of  an  angioma  or  vascular  caruncle  at  the  orifice 
of  the  urethra ;  from  the  repeated  sexual  act  in  nervous  girls  full  of 
sexual  disgust ;  and  also  from  repeated  ineffective  union  of  a  feeble 
male  with  a  sexually  disposed  female  inducing  a  hyperactive  and  dis- 
satisfied spasmodic  muscular  state. 

By  direct  force,  as  a  fall  or  blow,  cystic  tumours  may  be  ruptured,  of 
which  the  effects  are  described  under  ovarian  cystoma,  and  a  myoma 
may  be  bruised,  causing  venous  extravasation  and  peritonitis,  and  per- 
haps its  necrosis. 

Of  the  operative  causes  of  disease,  the  introduction  of  any  kind  of 
dirty  instrument  may  convey  septic  germs,  as  of  the  sound  tainted  with 
gonorrhoeal  matter.  Or  force  may  effect  a  minute  necrosis,  which  may 
induce  inflammation,  as  in  the  attempt  to  pass  a  sound  otherwise  than 
in  the  line  of  the  uterine  canal,  whence  may  result  endometritis  ;  or  if  it 
perforate  the  peritoneum,  as  in  some  cases  of  the  production  of  criminal 
abortion  —  peritonitis. 

The  forcible  replacing  of  an  adherent  uterus  may  rupture  vascular 


148  SYSTEM   OF  GYNECOLOGY 

adhesions  about  the  uterus  or  Fallopian  tubes,  or  a  follicular  cyst, 
■whence  peritonitis. 

The  application  of  irritants,  such  as  carbolic  acid  or  iodine,  to  the 
endometrium,  particularly  when  the  cervical  canal  is  narrow  and  obstruc- 
tive, readily  puffs  up  the  glandular  structures  sufficiently  to  close  the 
inner  or  outer  os.  When  the  escape  of  the  secretions  is  hindered,  retlex 
irritation  results,  the  muscular  fibres  contract  spasmodically  and  pain- 
fully, and  endometritis  ensues.  This  is  the  more  apt  to  occur  when 
there  exists  an  angle  of  flexion  in  the  uterus,  which  may  be  anteflexed 
or  retroflexed ;  and  the  two  conditions  of  a  narrow  canal  with  anteflex- 
ion are  usually  coincident  in  the  uterus  of  feeble  development.  Thus  if 
endometritis  have  previously  existed,  it  is  accentuated,  and  evolutionary 
progress,  described  in  section  1,  proceeds. 

A  yet  more  vigorous  action  in  the  same  direction  may  be  from  the  intro- 
duction of  the  tent,  whether  sponge,  laminaria,  tupelo,  or  slippery  bark ; 
since  necessarily,  by  their  presence,  there  is  a  temporary  suspension  of 
escape  of  secretions,  which  are  augmented  by  the  pressure  on  and  irritation 
of  the  endometrial  glands  by  the  part  of  the  tent  within  the  uterine  body. 
If  the  condition  of  the  endometrium,  for  the  diagnosis  or  treatment  of 
which  the  tent  is  used,  be  already  inflammatory,  the  endometritis  may  be 
increased.  If  not,  such  tents,  and  particularly  when  of  sponge,  rapidly 
become  septic,  and  the  secretions  retained  in  the  uterine  cavity  are  thus 
tainted,  and  evolutionary  disease,  through  fimbrial  effusion,  may  advance. 

In  the  dilatation  some  laceration  of  the  interglandular  structures 
results,  and  the  sponge  insinuates  itself  into  the  gland-ducts  themselves, 
so  that  such  raw  surfaces  are  the  more  liable  to  be  septically  infected ; 
and  particles  of  this  septic  sponge  may  be  retained  after  withdrawal  of 
the  mass.     A  temperature  of  105°  may  thus  be  rapidly  produced. 

An  intra-uterine  stem,  which  is  usually  more  permanent,  is  similarly 
injurious  by  creating  or  increasing  endometritis  by  pressure  and  obstruct- 
ing drainage. 

Injections  of  fluid  maybe  introduced  into  the  uterus  unintentionally 
by  chance  pressure  of  the  vaginal  tube  through  a  lacerated  or  dilated  cer- 
vix, and  obstructing  the  canal,  may  pass  through  the  tube  into  the  perito- 
neal cavity,  and  induce  peritonitis  ;  or  intra-uterine  injections,  made  with 
a  fine  tube,  may  be  retained  within  the  uterine  cavity  l)y  angularity  or 
stenosis,  or  hyperplastic  approximation  of  the  walls  of  the  canal,  and  in- 
duce colic  and  endometritis  ;  or  perchloride  of  mercury  nuxy  be  absorbed, 
and  produce  acute  nephritis  and  anuria,  resulting  in  urijemic  death,  due 
provision  for  its  return  not  having  been  made;  or  the  cervical  canal 
may  be  thickened  by  the  irritation  and  become  stenosed. 

Probably  few  operative  measures  more  frequently  causes  or  exaggerate 
disease  than  [lessaries.  They  ai'c  always  septic  by  accumulation  of  secre- 
tion about  them,  and  thus  pres(;nt  to  any  abraded  spot,  which  tliemselves 
may  have  created,  the  bacteria  of  inflammatory  action.  J^y  continuous 
pressure  on  the  vagina  they  are  liable  to  produce  necrosis,  and  nstaining 
bands  may  be  Un-nunl  across  thfur  Ijars  ;  or  ih(!y  may  embed  themselves 


ETIOLOGY  OF  DISEASES   OF  FEMALE    GENITAL    ORGANS     149 

in  the  rectum  or  bladder.  By  constant  expansion  permanent  dilatation 
of  the  vaginal  muscular  fibres  and  the  destruction  of  the  vaginal  colmnn 
may  be  effected;  while,  if  there  be  vaginal  subinvolution,  this  is  con- 
tinued and  usually  accentuated.  By  the  separation  which  they  cause 
the  faces  of  the  lacerated  cervix  are  everted ;  and  if  the  upper  limb  in- 
sinuate itself  between  them  a  deep  furrow  is  created,  and  about  it  the 
hyperplasia,  by  irritation  of  the  interglandular  structure,  is  increased. 
The  body  of  the  retroflexed  uterus  often  falls  back  on  the  upper  limb  of 
the  pessary  and  becomes  very  tender,  showing  that  peritonitis  has  been 
induced,  probably  from  effusion  from  the  fimbria  of  a  compressed  or 
bent  tube ;  and  if  a  larger  instrument  be  employed  the  preceding  dis- 
advantages are  the  more  apparent. 

When  evolutionary  disease  has  already  created  salpingitis,  peritonitis, 
and  perhaps  follicular  disease  of  the  ovaries,  there  are  usually  adhesions ; 
and  the  pressure  of  the  pessary  on  these  affected  parts  tends  to  irritate 
them,  and  increase  the  rapidity  of  progress  or  recurrence  of  their  diseases. 
Moreover,  the  pressure  on  an  ovary  congests  it,  or  may  effect  rupture  of 
a  follicular  cyst  with  resulting  peritonitis. 

A  metrotomy  by  scissors,  which  divides  the  circular  muscular  fibres 
so  that  the  faces  are  everted,  produces  the  effects  of  that  degree  of  lacera- 
tion without  subinvolution  ;  and  induces  or  accentuates  endometritis.  If 
the  operation  be  performed  with  a  two-bladed  metrotome,  an  unequal  or 
excessive  division  may  divide  a  vessel  into  the  broad  ligament,  whence 
may  result  an  extensive  haematocele,  which  may  become  septic ;  the  pas- 
sage of  the  knife  through  the  lateral  vaginal  fornix  may  have  similar 
results ;  or,  in  an  irregular  division,  the  blood  may  escape  into  the  peri- 
toneum. 

If  the  OS  be  closed  by  operation,  as  by  excessive  suturing  in  trache- 
lorrhaphy, or  cicatrisation  with  contraction  after  a  small  metrotom}-,  the 
secretions  —  such  as  blood  and  mucus  after  coincident  curettage,  and  the 
catamenia  —  are  retained  in  the  uterus  and  tubes,  may  distend  them,  and 
escaping  through  the  fimbria  into  the  abdominal  cavity,  produce  peri- 
tonitis. This  may  or  may  not  be  virulent,  according  to  the  quality  of  the 
sepsis  or  degeneration  and  quantity  of  the  fluid  thus  effused.  If  secretions 
be  retained  in  the  cavity  of  the  uterus  with  stenosis  of  the  os  by  such 
intermittent  causation,  they  are  likely  to  become  septic,  and  endometritis 
results,  and  perhaps  further  disease. 

In  puncture  with  a  trocar,  for  exploration  or  treatment,  if  the  instru- 
ment be  septic,  putrefactive  germs  may  be  introduced,  and  necrosis  and 
septicsemia  result;  this  may  happen  in  a  myoma  pierced  by  an  explora- 
tory trocar  or  electric  needle. 

The  introduction  of  an  exploratory  trocar  into  a  solid  abdominal 
tumour  is  liable  to  be  followed  by  peritoneal  ha?matocele,  which,  if  aseptic 
and  in  moderate  quantity,  may  be  absorbed,  and  in  part  contract;  but  if 
too  large  for  nutrition,  it  may  undergo  necrosis  and  become  purulent; 
it  will  certainly  do  this  if  septic  by  escape  of  necrosed  tissue  from  the 
puncture  in  the  tumour. 


SYSTEM  OF  GYNAECOLOGY 


If  the  tumour  contain  fluicV,  some  of  it,  and  perhaps  much,  may  ooze 
through  the  small  opening  after  the  withdrawal  of  the  canula.  If  such 
escape  be  into  the  peritoneum,  the  peritonitis  is  proportionate  to  the 
degree  of  virulence  and  the  quantity  of  the  fluid,  as  well  as  of  the  septic 
influence  of  the  operation,  an  influence  perhaps  due  to  admission  of  air 
through  the  canula:  similarly,  pelvic  cellulitis  may  thus  be  erysipe- 
latous and  pysemic. 

The  withdrawal  of  the  liquor  amnii  from  a  tubal  extra-uterine  foetation 
is  liable  to  be  followed  by  escape  of  blood;  and,  on  removal  of  the 
canula,  some  may  pass  into  the  abdominal  cavity.  The  vitality  of  the 
ovum  may  thus  be  destroyed,  and  its  necrosis  occur  with  tainting  of 
the  escaped  clot,  whereby  a  progressive  and  finally  virulent  peritonitis 
is  produced. 

In  the  operative  puncture  of  a  dermoid  cyst,  the  canula,  blocked  by 
the  fat  and  hair,  may,  in  its  removal,  discharge  some  of  the  sac  contents 
into  the  peritoneum,  inducing  peritonitis ;  and  the  inflammation,  extend- 
ing through  the  opening  made,  may  affect  the  lining  wall  of  the  sac,  and 
produce  pus  formation,  or  septic  suppurative  germs  may  be  thus  intro- 
duced directly. 

Perforation  of  the  intestine,  so  that  the  gases  and  fseces  escape  into 
the  peritoneum,  is  intensely  and  virulently  inflammatory  from  the  pres- 
ence of  the  bile,  bacteria,  and  matters  decomposed  or  ready  for  decom- 
position. In  leaking  puncture  of  the  bladder,  healthy  effused  urine  is  in 
itself  non-irritating ;  but  if  unhealthy  or  decomposing,  or  in  excessive 
quantity,  very  irritating. 

In  the  treatment  of  abortion,  undue  haste  may  induce  attempt  at 
removal  of  the  ovum  before  separation  of  the  chorionic  villi  or  placenta 
has  taken  place,  so  that  part  remains  in  a  necrosing  state  in  the  uterus ; 
or  curettage  may  be  practised  thereon,  or  deeply  on  the  prominent 
placental  site,  from  want  of  knowledge  that  such  projection  is  normal. 

Any  operation  in  which  the  peritoneum  is  opened,  and  septic  germs  or 
disorganising  fluids,  gases,  or  solids  are  admitted,  may  lead  to  peritonitis 
of  a  degree  proportionate  to  the  quality  and  quantity  of  such  irritating 
agent. 

W.  Balls  -  Headley. 


REFERENCES 

1.  Baldy.  Text-hook  of  GynsRcolor/y.  —  2.  Balfour,  F.  M.  "  On  the  Origin  and 
History  of  the  Uro-genital  Organs  of  Vertelirata,"  JourntU  of  Anatomy  and  Physiology, 
vol.  X.  1870;  "On  the  Structure  anrl  Development  of  the  Vertehrate  Ovary,"  Quarterly 
Jour,  of  Mi.croncop.  Sci.  vol.  xviii.  1878. — .'5.  Bantock.  "On  the  Pathology  of  certain 
so-called  Unilocular  Ovarian  Cysts,"  Tranx.  Obstet.  Soc.  vol.  xv.  —  4.  Barnks.  7Vte 
Dwaaeii  of  Women.  —  T>.  Bkddard.  F.  E.  "  Ohservations  on  the  Ovarian  Ovum  of 
Lepidosiren,"  Proceed,  of  the  Zool.  Sac.  of  London,  Mny  4,  ]88().  —  (!.  IjEi.l,  F.  J.  Com- 
parative Anatomy  and  J'/tys.  — 7.  Cai.dkrwooij.  "  On  the  Ova  of  Teloosteans,"  Jour, 
of  tlie  Marine  Biol.  Assoc,  of  the  United  Kiny.,  new  series,  vol.  ii.  No.  4.  —  8.  Coats,  J. 
Manual  of  Pat.holoyy.  — !).  Cunningham.  Journal  of  the  Marine  Jiiol.  Assoc,  of  the 
United  Kinr/dom,  new  series,  vol.  ii.  No.  1;  vol.  iii.  No.  2.  — 10.  Cullincworth.  On 
Pelvic  (Jellulitis. — 11.  Darwin.     The  Descent  of  Man;  The  Oriyin  of  Species.  — 12. 


DIAGNOSIS  IN  GYNECOLOGY  151 

DoRAX,  Alban.  "  On  Myoma  and  Fibro-Myoma  of  the  Uterus  and  Allied  Tumours  of 
the  Ovaries,"  Trans.  Obstet.  Soc.  vol.  xxix. ;  Tumours  of  the  Ovary.  — 13.  Emmet. 
Principles  and  Practice  of  Gynxcologij.  — 14.  Garkigues,  H.  J.  Diseases  of  Women.  — 
15.  Geddes,  p.  Ency clopiBdia  Brit.  vol.  xx.  p.  408;  vol.  xv.  p.  3<J8.  — 16.  Geddk.s 
and  Thompsox.  Comparative  Anatomy.  — 17.  Getjen-baur.  Elements  of  Comparatire 
Anatomy.— \?,.  Grky's  Anatomy.  —  lii.  Habershox.  Diseases  of  the  Abdomen.  —  20. 
Hamilton,  D.  J.  Textbook  of  Patholofiy.  —  'll.  Hart,  D.  Berry.  Female  Pelvic 
Anatomy. — 22.  Kikkes.    Handbook  of  Pliysiology.  —  23.  Mixot.    Human  Embryology . 

—  24.  Napier,  Leith.  "Habitual  Abortion,"  Ohst.  Trans,  vol.  xx-xii.  1890.  —  25. 
Playfair,  W.  S.  The  Science  and  Practice  of  Midwifery  ,  "  On  Removal  of  the  Uterine 
Appendages  in  Cases  of  Functional  Neurosis,"  Obst.  Trans,  vol.  xxxiii.  1891.  —  2(5.  Pozzi. 
Medical  and  Surgical  Gynecology.  — 27.  Ruffer,  A.  Quar.  Jour,  of  the  Microscop.  Soc. 
vol.  XXX.  Part  4,  Feb.  18!K).  —  28.  Savage.  On  the  Female  Pelvic  Organs.  —  29.  Schacht. 
"On  Ruptured  Tubal  Gestation,"  Brit.  Gynxcol.  Jour.  Nov.  1893.  —  .30.  Schultze, 
Trans,  by  Macan.  Displacements  of  the  Uterus. — 31.  Shattock,  S.  G.  The  Morton 
Lecture  on  Cancer,  May  19, 1894.  —  32.  Snow,  H.  The  Proclivity  of  Women  to  Cancerous 
Diseases;  On  Cancers  and  the  Cancerous  Process.  —  33.  Suttox,  Bl.\nd  J.  Surgical 
Diseases  of  the  Ovaries  and  Fallopian  Tubes;  Evolutio)i  and  Disease.  —  34.  Tait, 
Lawson.  Diseases  of  Women  and  Abdominal  Surgery;  Diseases  of  the  Ovanes ; 
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Thornton,  Knowsley.  "Three  Hundred  Additional  Cases  of  Ovariotomy,"  Med. 
Chir.  Trans,  vol.  xx. ;  "Cases  Illustrating  the  Surgery  of  the  Kidney,"  Lancet,  1S95. 

—  37.  Wells,  Sir  Spencer.    Diseases  of  the  Ovaries ;  Ovarian  and  Uterine  Tumours.  — 

38.  Wiedersheim.     Grundriss  der  Vergleiche)iden  Anatomic  der  Wirbelthiere,  \S93. — 

39.  Williams,  J.  W.  "  Tuberculosis  of  the  Female  Generative  Organs,"  Johns  Hopkins 
Hospital  Reports  in  Pathology,  \\.  Baltimore,  1892.  —  40.  Winkel,  by  Chadwick.  On 
Childbed.  —41.  Woodhead,  G.  S.  "  Practical  Pathology:  An  Address  on  the  Channels 
of  Infection  in  Tuberculosis,"  Lancet,  Oct.  27,  1894. 

W.  B.-H. 


DIAGNOSIS   IN   GYNAECOLOGY 

The  differential  diagnosis  of  particular  diseases  will  be  found  under 
their  respective  headings  in  the  several  articles  of  this  volume.  The 
object  of  this  article  is  to  collate,  with  a  view  to  diagnosis,  the  various 
symptoms  and  physical  signs  met  with  in  the  diseases  peculiar  to  women. 
The  subject  naturally  resolves  itself  into  two  parts  —  the  history  of 
the  patient  and  the  physical  examination  ;  and  it  will  be  treated  under 
these  headings. 

The  history  of  the  patient.  —  For  purposes  of  reference  a  note 
should  be  made  of  the  date,  and  of  the  name  and  address  of  the  patient. 
The  investigation  may  be  conveniently  carried  out  in  the  following 
order : — 

xirje.  —  The  age  of  the  patient ;  whicli  has  a  direct  bearing  on  many 
matters — such  as  menstruation  and  child-bearing.  Before  the  age  of 
ten  menstruation  is  naturally  absent ;  and  again  after  the  age  of  fifty : 
though  even  in  healthy  persons  the  dates  of  onset  and  cessation  vary 
within  wide  limits.  Impregnation  occurs  only  during  the  period  of 
active  menstrual  life.  The  age  of  the  patient  is  often  of  importance 
also  in  deciding  upon  the  nature  of  disease.  For  instance,  cancer  rarely 
occurs  before  thirty  or  forty  years  of  age,  and  more  often  about  the 


152 


SYSTEM   OF  GYNECOLOGY 


time  of  the  menopause.  IsTeverfclieless,  we  must  not  forget  that  cases 
occasionally  occur  at  an  earlier  age  ;  I  have  seen  the  disease  in  an 
advanced  stage  at  the  age  of  twenty-nine,  and  even  so  early  as  twenty- 
five. 

Social  Condition. — Information  as  to  marriage  or  spinsterhood,  or, 
again,  whether  the  patient  be  widowed  or  separated  from  her  husband, 
has  often  an  important  bearing  in  determining  the  question  of  pregnancy, 
and  in  affording  presumptive  evidence  of  sexual  intercourse.  And  the 
further  information  as  to  the  length  of  time  the  patient  has  been 
married,  widowed,  or  separated,  as  the  case  may  be,  is  often  a  necessary 
factor  in  deciding  these  important  questions.  Many  diseases  occur 
only  in  connection  with  gestation ;  others  only  as  the  outcome  of  deliv- 
ery ;  others  again  follow  sexual  intercourse.  A  note  of  these  matters, 
therefore,  often  provides  a  valuable  step  towards  diagnosis. 

Occupation.  —  The  occupation  of  the  patient  has  often  a  material 
bearing  upon  the  disease  from  which  she  suffers.  For  instance,  cooks, 
charwomen,  and  laundresses,  being  constantly  on  their  feet  and  exposed 
to  a  hot  and  often  steamy  atmosphere  which  tends  to  relax  the  tissues, 
are  specially  disposed  to  various  forms  of  prolapse.  In  the  case  of 
married  women,  it  is  well  to  ascertain  the  occupation  of  the  husband ; 
for  many  deductions  may  be  drawn  from  this  knowledge.  The  occupa- 
tion of  the  husband  not  only  affords  some  notion  of  the  means  of  the 
patient,  but  often  leads  up  to  some  conclusion  concerning  the  nature 
of  the  illness.  Take,  for  instance,  the  case  of  a  patient  suffering  from 
vaginal  discharge,  one  in  which  it  is  difficult  and  yet  important  to 
determine  whether  the  discharge  be  merely  an  ordinary  leucorrhcea  or 
a  gonorrhoea :  now  there  are  certain  classes  of  the  community  on  the 
male  side  —  and  therefore  on  the  female  side  also,  when  they  happen  to 
be  married  —  who  are  particularly  prone  to  gonorrhoea,  such  as  soldiers, 
sailors,  and  policemen.  In  these  cases  additional  information,  sufficient 
to  warrant  a  diagnosis,  can  usually  be  obtained. 

Leading  Symptoms  of  which  Complaint  is  made.  —  Having  made  a  note 
of  the  foregoing  preliminary  particulars,  it  is  well  before  making  further 
inquiries  to  ascertain  generally  from  the  patient  the  precise  symptom  or 
symptoms  of  which  she  complains.  Patients  often  give  a  very  indirect 
answer  to  the  question,  "  What  is  it  you  complain  of  ?  "  —  such  a  reply  as 
''  the  insides  "  or  "  the  womb  "  ;  and  they  are  apt  to  give  as  their  answer 
(often  with  considerable  modification)  what  any  doctor  who  has  been 
previously  consulted  may  have  told  them.  It  is  then  necessary  to  inquire 
what  brought  her  to  seek  advice.  In  the  vast  majority  of  cases  it  will  be 
found  that  actual  pain  or  discomfort  in  some  part  or  other  is  the  leading 
symptom  from  which  the  patient  seeks  relief.  But  in  some  cases  pain 
may  be  entirely  absent,  or  only  present  under  certain  conditions,  as,  for 
instance,  during  coitus  ;  or  sexual  intercourse  may  be  (vffoclxul  with  diffi- 
cidty  or  even  be  impossible.  Others  will,  perhaps,  speak  of  a  swelling  in 
the  aV>domen  as  the  leading  featui-e  in  the  case.  Some,  again,  will  apply 
for  advice  because  there  is  no  family  ;  tlicy  feid  well  in  every  respect, 


DIAGNOSIS  IN  GYNECOLOGY  153 

but,  having  been  married  for,  perhaps,  some  two  or  three  years,  and  no 
family  resulting,  they  come  for  advice  on  that  matter.  In  many  of 
these  cases  there  is  no  particular  illness  or  discomfort,  but  it  will  be 
found  that  in  the  vast  majority  of  them  some  morbid  condition  is  pres- 
ent. The  points  with  reference  to  which  the  jiatient  makes  complaint, 
and  the  approximate  length  of  time  during  Avhich  she  has  experienced 
each  symptom,  should  be  noted.  These  inquiries  will  probably  afford 
some  clue  to  the  nature  of  the  case,  will  indicate  the  line  an}'  special 
investigation  should  take,  and  will  serve  as  a  foundation  on  which  to 
construct  the  diagnosis.  The  object  of  the  present  article,  however,  is 
not  to  take  up  the  leading  individual  symptoms  of  which  the  patient 
complains,  and  then,  by  following  the  clues  thus  obtained,  gradually  to 
elaborate  a  diagnosis  ;  but  rather  to  provide  a  general  systematic  form 
of  investigation  which  will  be  found  serviceable  in  the  vast  majority  of 
gynaecological  cases.  After  these  preliminary  inquiries  the  symptoms 
and  discomforts  of  which  the  patient  complains  can  be  sifted  and  am- 
plified. This  method  of  inquiry  provides  a  very  valuable,  but  often 
neglected  quantity  of  negative  evidence.  For  it  often  happens  that  the 
patient  comes  complaining  of  something  which  may  be  but  a  trivial 
deviation  from  health;  yet,  if  her  case  be  gone  into  systematically 
and  carefully,  according  to  the  method  I  propose,  important  informa- 
tion will  be  forthcoming  which  Avill  enable  us  to  find  or  suspect,  even 
before  we  go  into  physical  examination,  that  she  has  some  other  and 
concomitant  disease,  either  quite  independent  of  the  matter  of  which 
she  makes  complaint,  or  entirely  subservient  to  it. 

Having  ascertained,  then,  the  main  points  to  which  the  patient  wishes 
to  draw  attention,  and  for  the  relief  of  which  she  seeks  advice,  it  is  well 
to  proceed  to  ascertain  the  menstrual  and  obstetric  history  of  the  case. 

The  Menstrual  History.  —  At  the  outset  let  me  emjihasise  a  point  to 
which  too  little  attention  is  given,  namely,  that  in  order  to  obtain  first 
from  the  patient  a  menstrual  history  of  so  complete  a  character  as  to 
answer  the  purposes  of  investigation,  it  is  necessary  to  ascertain  the 
normal  character  of  the  menstruation  in  the  individual.  For  there  are 
among  women  wide  individual  differences  in  respect  of  this  function.  In 
order  to  judge  whether  any  change  has  taken  place  in  the  menstruation 
of  any  woman  after  its  first  commencement,  the  natural  character  of  her 
own  menstruation  must  be  determined  in  the  first  instance.  A  certain 
feature  of  the  function  which  in  one  woman  might  be  considered  an 
abnormal  variation  may  be  the  usual  and  natural  condition  in  another. 
And  therefore,  I  repeat,  that  in  each  individual  case  it  is  necessary  to 
ascertain  the  individual  character  of  the  function  in  order  to  appreciate 
the  importance  of  any  change  in  it. 

The  points  in  the  history  of  menstruation  to  which  attention  should 
be  directed  are  as  follows:  — 

Tlie  Age  of  Commencement.  —  Menstruation  begins  earlier  in  some 
women,  later  in  others ;  it  usually  begins  between  the  thirteenth  and 
fourteenth  year.     In  hot  climates  it  begins  at  an  earlier  age;  and  it 


154  SyST£A/   OF  GYNECOLOGY 

varies  also  in  different  races.  ^  It  begins  sometimes  as  early  as  the 
eighth  Or  ninth  year ;  sometimes  it  does  not  begin  till  the  eighteenth, 
nineteenth,  or  twentieth.  And  these  variations  occnr,  be  it  noted, 
altogether  apart  from  disease  —  such  as  anaemia. 

Tlie  Rhythm  of  the  Flow.  —  It  often  happens  that  after  the  first  period 
or  two  the  patient  sees  nothing  again  for  some  months,  perhaps  for  a 
year  or  more.  After  the  lapse  of  some  time  the  flow  recommences  and 
continues  regularly.  We  are  frequently  consulted  in  such  cases.  A 
girl  —  say  of  twelve  or  thirteen,  or  a  little  older  —  has  menstruated 
once,  but  the  flow  has  not  been  succeeded  by  others  in  the  ordinary 
way ;  she  is  consequently  brought  by  her  mother  to  the  physician  with 
a  view  to  treatment.  These  cases,  as  a  rule,  require  no  treatment  if 
the  patient  be  generally  in  a  healthy  condition,  and  has  not  exceeded 
the  age  at  which  menstruation  usually  begins.  It  should  be  recognised 
that  in  some  individuals  it  is  natural  for  one  flow  to  show  itself,  or 
perhaps  for  two  or  more  to  appear,  and  then  for  the  courses  to  remain 
in  abeyance  for  some  months,  often  for  a  year  or  longer,  before  the 
rhythmical  flow  is  established. 

Change  of  residence,  especially  from  the  country  to  London,  is  often 
attended  with  cessation  of  the  flow  during  the  stay ;  it  returns,  how- 
ever, subsequently,  and  in  the  meantime  the  general  health  is  unaffected. 

With  most  women  the  flow  comes  on  at  intervals  of  twenty-eight  or 
thirty  days.  In  some  women,  however,  it  appears  at  shorter  intervals 
—  from  two  to  three,  or  more  frequently  still,  from  three  to  four  weeks. 
In  others  the  intervals  are  prolonged,  and  the  menses  recur  after  an 
interval  of  five  to  six  weeks,  and  sometimes  longer ;  yet  these  patients, 
so  far  as  one  can  judge,  are  in  perfect  health,  and  the  menstrual  func- 
tion is  otherwise  performed  in  a  proper  and  natural  manner.  It  will  be 
found  on  inquiry  that  such  peculiarities  are  natural  to  the  individuals. 

In  other  patients,  again,  the  menses  do  not  occur  regularly,  and  this 
in  patients  who  have  gone  on  for  years  without  any  illness  or  disturb- 
ance to  account  for  the  irregularity.  Such  persons  are  never  quite  reg- 
ular, but  if  they  complain  of  no  illness,  irregularity  must  be  looked 
upon  as  the  regular  thing  for  them,  and  is  not  necessarily  to  be  regarded 
as  jjathological. 

77ie  Duration  of  the  Flow.  —  Here  again  considerable  variation  is 
found  within  physiological  limits.  In  the  majority  of  women  the  period 
lasts  four  or  five  days;  in  others  it  lasts  a  shorter  time,  —  very  often 
only  one  day,  and  even  in  some  cases  but  a  few  hours.  In  others  the 
flow  continues  four,  five,  six,  seven,  or  eight  days,  or  even  a  little  more 
without  the  presence  of  any  abnormal  condition  or  any  interference,  so 
far  as  one  can  learn,  with  the  general  health.  In  some  women  it  by 
no  means  infrequently  happens  that  the  flow  comes  on  for  a  day  or  two, 
then  stops  for  a  day  or  two,  and  again  comes  on  for  two  or  three  days. 
This  again,  being  the  natural  condition  of  some  individuals,  is  not  by 
any  means  necessarily  pathological.  In  others  it  will  bo  found  that 
without  being  pathological    the  period  lasts   a  variable  time;    some- 


DIAGNOSIS  IN  GYNAECOLOGY  155 

times  it  may  last  a  day  or  two,  at  other  times  rather  longer ;  occasionally 
it  is  extended  over  a  week.  The  duration  of  the  flow  in  such  cases 
depends  in  great  measure  on  what  the  patient  is  doing  at  the  time  — 
the  more  active  the  patient's  life  the  more  extended  the  periods. 

The  Daily  Amount.  — As  a  rule,  the  longer  the  flow  the  greater  the 
amount  of  daily  loss.  But  in  this,  too,  there  is  room  for  considerable 
variation  Avithout  exceeding  physiological  limits.  It  is  diflicult  to 
estimate  the  amount  of  the  daily  loss  ;  but  a  rough  guide  may  generally 
be  obtained  from  tlie  patient  by  ascertaining  the  number  of  diapers 
which  she  uses  during  a  period,  or  during  each  day  of  the  flow.  Some 
patients  assert  that  they  never  have  been  able  to  wear  a  diaper,  as  it 
stops  the  flow.  Fortunately  such  persons  do  not  lose  very  much.  Of 
course,  in  using  this  guide  to  the  loss,  due  allowance  must  be  made 
for  individual  habits  of  cleanliness ;  for  while  some  will  only  let  the 
diapers  become  partially  soiled,  others  will  be  less  nice.  Still  the 
number  of  diapers  serves  fairly  as  a  rough  estimate  of  the  daily  loss. 
If  a  patient  tell  you  that  diapers  are  "  no  good  at  all,"  and  that  she  has 
to  put  on  two  or  three  at  a  time,  or  uses  big  cloths  or  towels,  you  may 
be  quite  sure  she  is  losing  very  freely.  Such  information  is  exceedingly 
valuable  and  suggestive.  Some  patients  will  even  go  further,  and  say 
that  they  have  to  lie  up  during  the  period,  and  put  something  under 
them  to  protect  the  bed-clothes,  the  loss  being  so  copious.  The  usual 
average  is,  perhaps,  three  or  four  a  day  —  say,  one  to  two  during  the 
day,  and  one  at  night ;  or  sometimes  three  during  the  day,  and  one  at 
night.  When  the  patient  is  up  and  about,  the  more  active  she  is  the 
more  she  loses,  and,  generally  speaking,  the  loss  is  less  at  night. 
When  the  amount  of  the  daily  loss  is  great,  it  is  very  likely  that  clots 
will  be  passed  at  the  same  time  ;  generally  speaking,  the  more  copious 
the  discharge  the  greater  the  liability  to  the  passage  of  clots.  As  a  rule 
the  menstrual  fluid  does  not  clot  unless  it  be  very  free  in  amount.  These 
clots  may  be  quite  small ;  or  they  may  be  of  considerable  size,  as 
big  as  the  thumb,  or  even  larger ;  in  this  case  they  are  due  to  an 
accumulation  of  blood  in  the  vagina  and  its  subsequent  coagulation.  The 
passage  of  clots  is  more  usual  in  women  who  have  borne  children.  With 
the  flow  there  may  also  be  shreds,  which  are  often  looked  upon  as  clots 
by  the  patient ;  but  they  can  be  distinguished  by  the  fact  that  shreds 
float  out  in  Avater.  Such  a  condition  is  associated  Avith  severe  pain,  and 
is  pathological. 

Pain,  again,  varies  in  different  persons,  though  short  of  that  Avhich  is 
of  so  severe  a  character  as  to  come  under  the  head  of  dysmenorrh(>?a. 
In  some  patients  at  the  time  of  menstruation  there  is  absolutely  no  pain 
and  practically  no  discomfort:  these  persons,  however,  are  rather  the 
exception  than  the  rule.  With  Avomen  generally,  as  the  floAv  approaches, 
there  is  a  sense  of  fulness,  congestion,  disturbance,  and  Aveight  in  the 
pelvic  organs.  They  become  more  highly  sensitive  at  that  time,  and  in  a 
very  considerable  number  of  cases  pain  is  present  in  greater  or  less  degree ; 
the  pain  may  be  at  the  bottom  of  the  l)ack.  in  the  lower  part  of  the  abdo- 


156  SYSTEM  OF  GYNAECOLOGY 

men,  or  may  be  referred  to  one  or  both  ovarian  regions.  "When  it  is  severe 
it  may  extend  beyond  these  points  to  the  hips,  or  down  the  thighs  as  far  as 
the  knee ;  in  other  eases  it  may  extend  np  the  abdomen,  even  to  the  level 
of  the  breasts.  The  amount  of  the  pain  may  be  roughly  estimated  by 
ascertaining  whether  the  patient  has  been  in  the  habit  of  taking  any 
remedies  for  its  relief  —  such  as  peppermint,  ginger,  or  alcohol  in  various 
forms,  especially  in  the  form  of  gin ;  or,  in  some  cases  where  medical 
advice  has  been  sought,  as  laudanum  and  even  hypodermic  injections  of 
morphia,  besides  various  other  remedies.  The  amount  of  the  pain  may 
be  gauged  also  by  the  patient's  answer  to  the  question  whether  she  has 
been  able  to  be  up  and  about  her  work,  whatever  it  be,  at  the  time 
of  the  period ;  or  whether  she  has  had  to  take  to  her  bed  for  a  longer  or 
shorter  time,  and  have  hot  local  applications —  such,  for  example,  as  a  hot 
brick  wrapped  up  in  flannel  (a  useful  means  of  removing  pain  in  some 
cases),  hot  sand-bags,  hot  fomentations,  stupes,  or  poultices. 

The  time  at  which  the  pain  begins  varies  in  different  individuals.  In 
some  the  pain  will  begin  a  day  or  two  before  the  flow,  in  others  a  few 
hours  before,  while  in  others  it  comes  on  with  the  flow.  It  varies  also 
in  duration:  generally  speaking,  it  begins  two  or  three  hours  before 
the  flow  and  stops  after  the  first  day ;  in  other  cases  it  is  continued  to 
the  end  of  the  second  or  third  day,  and  may  last  even  to  the  end  of  the 
period.  As  a  general  rule,  however,  the  pain  is  at  its  worst  during  the 
first  few  hours  of  the  flow,  and  begins  to  diminish  as  soon  as  the  flow 
has  come  on  freely. 

The  Attendant  Symptoms.  — In  some  patients,  as  I  have  said,  there  is 
no  pain  and  no  discomfort;  in  others,  severe  frontal,  occipital,  or  general 
headache,  sick-headache,  or  vomiting  may  be  present.  In  other  cases 
some  disturbance  of  the  bowels,  either  constipation  or  diarrhoea,  takes 
place  at  the  time  of  the  menses.  Most  patients,  especially  during  the 
earlier  part  of  the  period,  require  to  pass  water  more  frequently  than  at 
other  times ;  and  with  this  excessive  frequency  there  is  occasionally  a 
little  pain  in  micturition.  Occasionally  patients  complain  that  they  have 
fits  —  hysterical  fits  —  during  the  flow:  these  are  generally  weakly 
patients  who  are  below  par,  and,  being  subject  to  hysteria  at  other  times, 
their  tendency  to  it  is  increased  at  the  periods.  Epileptic  attacks  also 
seem  to  be  more  readily  induced  during  the  menstrual  flow  than  at 
other  times. 

Jjeucorrlupxi  is  a  symptom  rather  of  the  intermenstrual  period.  In  a 
healthy  woman  there  is  no  discharge,  or  very  little,  after  the  cessation 
of  the  menses  ;  but  some  women  have  naturally  a  little  discharge  of  a 
whitish  character  for  a  day  or  two  after  the  flow.  In  other  patients  it 
occurs  a  day  or  two  l)cfore  the  flow ;  in  others,  again,  it  goes  on  to  a 
greater  or  less  extent  during  the  whole  intermenstrual  interval.  This 
discharge  is  of  an  opaque,  whitish  character.  In  patients  who  are  re- 
duced in  health  there  is  a  liability  to  a  certain  amount  of  leucorrhoeal 
discharge  apart  from  any  local  pelvic  trouble.  Discharge  of  a  thick 
glairy  mucus  in  large  quantity  is,  however,  pathological ;  or  if  the  dis- 


DIAGNOSIS  IN  GYNECOLOGY 


157 


charge  become  yellowish  or  purulent  it  passes  the  physiological  bounds. 
Occasionally  a  peculiar  odour  may  be  noticed  with  a  menstrual  flow  which 
does  not  pass  the  physiological  limit;  but  foetid  discharges  are  invari- 
ably pathological. 

Abnormal  Variations.  —  The  date  at  which  the  deviation  from  the 
usual  course  took  place  must  be  ascertained.  This  deviation  may  take 
one  or  more  forms.  The  menses  may  have  come  on  too  frequently,  at 
shorter  intervals  than  previously;  they  may  have  come  on  quite  irreg- 
ularly ;  the  duration  may  have  increased  or  diminished,  or  the  daily  loss 
may  have  increased  or  diminished.  Tain  again,  previously  absent,  may 
have  become  a  prominent  feature.  In  any  case  we  should  ascertain  pre- 
cisely what  the  change  has  been,  and  the  time  at  which  it  set  in.  More- 
over, we  should  endeavour  to  ascertain  from  the  patient  herself  what  she 
considers  to  have  been  the  cause  of  this  change  in  menstruation.  It  will 
frequently  be  found  to  date  from  the  onset,  or  from  a  confinement  or  sub- 
sequent miscarriage,  or  it  may  have  begun  Avith  some  dehnite  illness. 

The  menopause  usually  sets  in  between  the  forty -fifth  and  the  fiftieth 
year.  Occasionally  it  occurs  earlier,  or,  on  the  other  hand,  it  may  be 
delayed  till  after  the  fiftieth  year.  Forty-eight  is,  perhaps,  the  average 
year  of  its  occurrence.  At  this  time  also,  as  at  the  beginning  of  the 
catamenial  periods,  the  menses  are  often  irregular.  Menstruation,  regu- 
lar up  to  a  certain  time,  may  suddenly  cease,  and  the  patient  see  noth- 
ing more.  Occasionally  the  courses  stop  for  a  month  or  two,  perhaps 
longer,  then  the  patient  has  a  period  or  two  at  irregular  intervals,  and 
after  this  they  cease  entirely.  In  other  cases  the  periods  gradually  get 
less  and  less  for  a  year  or  two  and  then  cease ;  in  others,  again,  the 
menopause  is  ushered  in  by  considerable  floodings.  It  is  often  difficult 
to  distinguish  these  changes  associated  with  the  menopause  from  the 
symptoms  of  distinct  and  serious  disease.  It  must  always  be  borne  in 
mind,  especially  in  the  case  of  flooding,  that  women  are  particularly 
liable  to  malignant  disease  at  this  time.  An  examination,  therefore, 
becomes  advisable  in  order  to  determine  whether  the  conditions  are 
physiological  or  due  to  some  disease  of  the  organs. 

Both  for  purposes  of  future  reference  and  as  a  guide  to  the  advisa- 
bility of  examination  by  means  of  the  sound,  inquiry  should  be  made 
as  to  the  date  of  the  onset  of  the  last  period,  and  the  time  at  which 
the  last  period  ceased. 

It  must  be  remembered  with  reference  to  this  point,  that  patients 
frequently  think  they  have  menstruated  when  actual  hccuuirrhage  has 
occurred  during  the  course  of  gestation.  Patients  will  frequently  come 
complaining  of  various  troubles,  and  stating  that  the  last  period  only 
ceased,  let  us  say,  a  week  ago ;  but  careful  inquiry  will  elicit  the  fact 
that  for  two  or  three  months  prior  to  that  time  they  had  seen  nothing 
at  all,  and  still  closer  investigation  will  show  that  this  so-called  last 
■'period"  had  not  the  character  of  natural  menstruation.  Whereas, 
perhaps,  the  patient  has  never  been  in  the  habit  of  passing  clots  before, 
these  appeari'd  in  the  discharge  on  the  occasion  referred  to  :  or,  although 


1 58  SYSTEM   OF  GYNECOLOGY 

the  periods  had  generally  lasted  a  week,  on  this  occasion  the  flow  had 
continued  for  two  or  three  days  only,  and  the  amount  lost  was  different. 

The  Obstetric  History.  — I  have  already  dealt  with  the  importance  of 
ascertaining  the  social  position  of  the  patient.  It  is  still  more  impor- 
tant to  know  what  has  been  her  obstetric  history  —  the  history  of  her 
labours  and  miscarriages,  if  any ;  because  a  very  considerable  amount  of 
illness  which  presents  itself  to  the  gynaecological  physician  is  the  result 
of  impregnation  and  of  disease  following  upon  delivery  or  abortion. 

The  first  points  to  ascertain  in  this  connection  are  the  number  of 
the  children,  and  the  date  of  the  last  delivery;  next,  whether  there 
have  been  any  miscarriages,  and  if  so,  when  they  last  occurred.  Indeed, 
it  is  a  good  plan  to  go  not  only  as  far  as  this,  but  to  ascertain  also  with 
regard  to  the  children  at  what  period  of  pregnancy  they  were  born, 
for  they  may  have  been  premature ;  and  as  to  the  miscarriages,  at  what 
period  of  gestation  they  took  place :  the  answers  are  to  be  entered  in 
their  order.  All  this  can  readily  be  recorded  in  very  short  compass  if 
we  put  down  the  labours  and  miscarriages  in  the  order  of  their  occur- 
rence, and  indicate  at  the  same  time  the  period  of  gestation  at  which 
each  of  these  events  took  place  by  means  of  figures  representing  months 
and  fractions  of  months. 

Where  premature  labour  has  occurred  or  miscarriage  taken  place,  it 
is  well  also  to  ascertain  from  the  patient  whether  any  particular  cause 
could  be  assigned  for  the  occurrence.  A  labour  may  be  brought  on 
prematurely,  or  a  miscarriage  may  be  induced  in  various  ways,  as  by  a 
fall,  a  fright,  a  blow,  a  strain,  over-work,  long  railway  journeys,  mental 
exhaustion,  and  so  forth ;  and  it  is  well  to  fortify  one's  self  with  this 
information.  Therefore  we  inquire  in  each  case  of  premature  labour 
what  cause  the  patient  can  assign  for  the  occurrence.  Of  course,  in 
many  cases  it  will  be  found  that  no  cause,  or  an  obviously  inadequate 
cause,  is  assigned  ;  and  it  is  in  these  cases  especially  that  the  immediate 
cause  may  be  found  in  or  about  the  uterus  —  such,  for  instance,  as  the 
presence  of  a  fibroid  in  the  uterus,  or  chronic  metritis  and  endometritis. 

Apart  from  the  question  of  prematurity,  the  character  of  each 
labour  should  be  ascertained  ;  whether  a  long  and  difficult,  or  an  easy 
one ;  and  if  long  or  difficult,  whether  it  was  aided  by  instruments. 
Patients  will  generally  vohmteer  the  information  if  "the  child  came 
the  wrong  way  "  ;  or  if,  as  they  say,  it  was  a  "  cross-birth."  The  "  cross- 
birth"  of  patients,  however,  is  by  no  means  invariably  what  the  physi- 
cian understands  by  that  name,  for  a  breech  presentation  is  also  usually 
dubbed  with  the  name  of  cross-birth.  In  order,  therefore,  to  make  sure 
that  the  case  was  in  reality  one  of  cross-birth,  it  is  necessary  to  inquire 
further  whether  turning  was  performed.  A  breech  would  probably  be 
delivered  as  such,  and  no  version  would  be  performed ;  but  if  tlio  ])atient 
states  that  she  was  chloroformed,  and  that  the  doctor  put  in  his  hand 
and  turned  the  child,  you  conclude  that  the  case  was  really  a  cross- 
birth,  and  not  a  bre(!ch  presentation. 

Again,  apart  fi'om  the  difficulty  of  the;  labours,  it  is  well  to  ascertain 


DIAGNOSIS  IN  GYNAECOLOGY  159 

whether  they  have  been  accompanied  by  flooding  or  not ;  and  whether 
there  has  been  any  tear  of  the  soft  parts  so  considerable  as  to  have 
necessitated  the  introduction  of  sutures. 

Illness  during  Pregnancy  and  after  Delivery.  — Ascertain  also  from  the 
patient  whether  her  health  continued  good  during  pregnancy.  Excessive 
sickness,  convulsions,  oedema,  and  flooding  should  be  particularly  inquired 
after.  Patients  are  generally  ready  to  inform  us  as  to  any  such  illnesses 
as  these.  With  regard  to  illness  after  delivery,  hoAvever,  unless  ques- 
tioned rather  closely,  patients  are  liable  to  mislead  the  doctor.  It  is 
well  to  ask  the  patient,  in  the  first  place,  whether  she  got  on  well  after 
the  child  was  born ;  and  if  in  any  doubt  as  to  her  answer,  ask  also 
how  long  she  kept  to  bed.  Patients  as  a  rule  do  not  keep  their  beds 
more  than  a  fortnight  after  delivery ;  if  that  period  has  been  exceeded 
the  chances  are  that  some  definite  illness  occurred  during  the  puerpe- 
rium.  It  does  not  necessarily  follow,  however,  that  because  the  patient 
was  able  to  get  up  after  the  lapse  of  ten  or  fourteen  days  that  she  had 
no  illness ;  for  such  illness  may  have  been  of  a  transitory  kind,  or 
she  ]nay  have  got  up  for  a  few  days  while  still  ill,  and  had  to  return 
to  bed  again  for  some  weeks. 

Illness  after  delivery  is  usually  of  a  febrile  character.  If  the  patient 
be  asked  whether  she  had  any  fever,  she  will  often  reply  that  she  had  a 
slight  touch  of  "  milk  fever."  We  shall  always  look  with  suspicion  upon 
such  an  ansAver,  which  probably  indicates  not  mere  mastitis,  or  a  local 
trouble  giving  rise  to  a  certain  amount  of  general  febrile  symptoms,  but 
more  often  than  not  it  indicates  some  illness  of  a  septic  nature.  Such  a  con- 
dition, in  order  to  prevent  alarm  on  the  part  of  the  patient  and  her  friends, 
and  sometimes — too  often  I  fear — -to  shield  the  reputation  of  the  doctor,  is 
put  down  as  milk  fever.  Mastitis  and  septic  mischief  have  this  in  common, 
that  both  usually  begin  about  the  second  or  third  day;  if,  hoAvever,  the 
illness  be  due  to  mastitis  the  breasts  as  a  rule  become  A^ery  hard  and  tender 
Avith  the  influx  of  milk  at  that  time,  and  the  disturbance  usually  subsides 
Avithin  tAvo  or  three  days  Avhen  the  fioAv  is  Avell  established.  On  the 
other  hand,  in  cases  Avhere  the  breasts  have  not  shoAvn  sj'mptoms  of  local 
disorder  (despite  the  fact  thatthepatient  callsthecondition  "milk  fever"), 
but  in  Avhieh  tenderness  and  pain  in  the  abdomen  (Avhich  you  can  gener- 
ally infer  from  the  use  of  hot  flannels,  hot  fomentations,  poultices,  or 
turpentine  stupes)  have  been  prominent  symptoms,  it  may  generally  be 
concluded  that  not  "  milk  fever,"  but  septic  mischief  of  local  origin 
Avas  present.  It  Avill  be  found  necessary  to  cross-question  patients  rather 
carefully  in  order  to  ascertain  these  facts.  If  the  patient  had  fever,  but 
is  unable  to  give  information  as  to  the  height  of  the  thermometer,  she 
Avill  often  be  able  to  afford  an  indication  of  the  severity  of  the  fever  by 
stating  Avhether  a  rigor  or  severe  shiver  occurred  at  the  outset  of  the 
illness.  It  may  be  taken  for  granted  that  a  rigor  at  the  outset  generally 
means  fever  running  up  quickly  to  rather  a  high  point.  In  long-con- 
tinued febrile  conditions  repeated  rigors  generally  occur  later  in  the  dis- 
ease; and  these  rigors  are  generally  associated  Avith  copious  perspirations. 


i6o  SYSTEM   OF  GYNAECOLOGY 

Again,  with  reference  to  the  general  condition  of  the  patient  suffering 
from  febrile  disease,  useful  additional  information  may  often  be  obtained 
by  inquiring  \^-hether  she  was  able  to  take  her  food  properly  while  lying- 
up ;  or  whether  she  had  to  be  kept  on  slops,  and  so  forth.  Finally,  if  a 
patient  tell  you  that  she  can  say  very  little  about  her  condition,  as  she 
was  unconscious  for  the  greater  part  of  the  time,  you  may  rest  assured 
she  was  delirious  as  well  as  febrile. 

The  conditions,  apart  from  febrile  illness,  which  keep  a  patient  in 
bed  longer  than  the  usual  time,  are  either  general  weakness,  from  some 
pre-existing  disease  or  from  haemorrhage  before  or  during  labour  or 
immediately  afterwards,  or  laceration  of  the  perineum,  or  some  inter- 
current disease,  such  as  pleurisy,  rheumatic  fever,  scarlet  fever,  or 
measles. 

Previous  Illnesses. — It  is  advisable  in  the  next  place  to  ascertain 
from  the  patient  what  previous  illnesses  she  may  have  had,  and  whether 
associated  with  the  pelvic  organs  or  not.  Many  of  the  troubles  com- 
plained of  will  be  found  to  date  from  illness  occurring  at  or  soon  after 
delivery  or  miscarriage.  But  it  may  frequently  be  found,  of  course,  that 
some  particular  symptom  takes  its  origin  from  disease  not  directly 
associated  with  the  pelvis :  for  example,  any  wasting  disease,  or  illness 
of  long  standing,  such  as  typhoid  fever  or  phthisis,  often  exerts  an  im- 
portant influence  on  the  menstrual  function.  Thus  at  the  beginning  of 
a  febrile  illness  there  may  be  severe  loss  of  blood,  especially  in  acute 
diseases  —  such  as  typhus  fever  and  small-pox  —  which  are  often  asso- 
ciated with  haemorrhage.  Again,  when  a  patient  has  been  laid  up  for 
a  considerable  time  by  prolonged  illness  —  such  as  typhoid  or  rheumatic 
fever,  the  periods  are  frequently  held  in  abeyance  for  a  long  interval, 
and  remain  so  until  she  regains  her  strength. 

The  History  of  the  Present  Illness.  —  We  should  ascertain  first  of  all 
the  date  at  which  the  j)resent  illness  began :  this  date  will  form  a  land- 
mark from  which  to  make  more  particular  inquiries.  We  should  ascer- 
tain also  the  cause  which  the  patient  assigns  for  her  illness,  as  this  will 
often  give  a  clue  of  considerable  value  to  the  nature  of  her  ailment. 

Of  the  particular  symptoms  to  which  attention  should  be  drawn  I 
put  pain  first,  because  it  is  one  of  the  most  common.  Under  this  head 
are  included  dysmenorrhoea,  that  is,  pain  at  and  associated  Avith  the 
menses ;  and  dyspareunia,  or  pain  and  difficulty  in  sexual  intercourse. 
Pain  in  association  with  the  functions  of  the  bowel  and  bladder  will  be 
dealt  with  under  the  bead  of  diseases  of  tliese  organs. 

Next,  inrpiii-ies  sliould  be  directed  to  ascertain  if,  in  f)th(n'  I'cspects, 
the  menstrual  function  has  been  naturally  performed.  Under  tliis  head 
are  menorrhagia,  metrorrhagia,  or  haemorrhage  during  tlio  natural  inter- 
vals of  the  periods;  amenorrhoea,  or  absence  of  the  periods  when  they 
ought  naturally  to  have  been  present ;  and,  finally,  leucorrhcea,  a  white 
or  yellowish  discharge  occurring  between  the  periods. 

Attention  shonhl  then  be  paid  to  the  question  of  local  swelling  or 
tumour,  wlic-ther  in  ilie  ])i'ivates  or  in  tlie  abdomen;  then  to  any  inter- 


DIAGNOSIS  IiV  GYNy^COIOGY  i6i 

ference  with  the  due  discharge  of  the  functions  of  the  bladder  and 
bowel ;  and,  finally,  to  such  general  symptoms  as  anaemia,  wasting, 
fever,  and  so  forth.  It  will  be  necessary  for  us  to  consider  these  mat- 
ters in  greater  detail,  and  to  enumerate  the  morbid  conditions  among 
which  these  symptoms  are  likely  to  be  found. 

Pain.  —  The  site  of  the  pain  must  be  noted,  whether  it  be  continu- 
ous or  spasmodic ;  and  its  character,  whether  it  be  sharp  and  cutting, 
or  dull  and  aching;  also  whether  it  be  associated  with  tenderness; 
whether  it  be  relieved  by  any  one  of  various  applications,  such  as  heat, 
cold,  pressure,  or  the  adoption  of  a  particular  posture,  and  in  Avhat  way 
it  is  apt  to  become  aggravated. 

The  causes  of  pain  in  the  pelvic  organs  are  very  various.  Inflamma- 
tory and  congested  conditions  stand  prominently  forAvard.  Under  this 
head  are  included  a  very  considerable  number  of  the  diseases  to  which 
women  are  specially  liable  :  such  are  pelvic  peritonitis  or  perimetritis  ; 
parametritis,  or  disease  of  the  cellular  tissue  of  the  pelvis ;  haematocele 
—  haemorrhage  into  the  pelvic  peritoneum  setting  up  pelvic  peritonitis  ; 
haematoma  —  haemorrhage  into  the  pelvic  cellular  tissue,  which  sets  up 
parametritis  and  perimetritis  in  its  neighbourhood ;  the  outcomes  of  in- 
flammatory mischief,  such  as  pelvic  abscess ;  inflammatory  disease  of 
the  appendages  (tubes  and  ovaries),  such  as  hydrosalpinx,  hsematosal- 
pinx,  and  pyosalpinx  ;  and  inflammation  of  the  uterus  itself  —  metritis. 
Among  the  congestive  conditions  I  may  mention  prolapsed  or  procident 
uterus,  and  prolapse  of  the  tubes  and  ovaries.  Adhesions,  or  rather  the 
stretching  of  adhesions  left  from  previous  inflammatory  mischief  due  to 
ovarian  or  tubal  disease,  are  a  frequent  cause  of  pain  and  discomfort ; 
and  so,  finally,  are  various  tumours  in  the  pelvis,  some  of  which  origi- 
nate in  the  uterus,  some  in  the  tubes  and  ovaries,  and  often  cause  press- 
ure and  pain,  especially  if  they  have  become  impacted. 

In  the  acts  of  micturition  and  defaecation  it  is  frequently  found  that 
pain  present  in  the  pelvis  becomes  aggravated,  especially  if  it  be  the 
result  of  inflammatory  conditions  and  adhesions.  In  other  cases  pain 
occurs  only  on  micturition  and  defaecation  ;  these  will  be  considered  later 
in  association  with  bladder  and  intestinal  troubles. 

Z)?/s23a?'ewnmmayoccur  from  various  causes.  It  is  frequent!}'' associated 
with  vaginismus.  This  condition  may  be  primary  or  secondary ;  that  is  to 
say,  it  may  have  existed  from  the  beginning  of  attempts  at  coitus,  or  it 
may  have  come  on  afterwards  as  the  outcome  of  some  other  difficulty  in 
the  act.  It  may  arise  from  inflamed  conditions  of  the  vagina,  from  what- 
ever cause;  from  excessive  indulgence  in  coitus,  or  from  gonorrh(i\al  in- 
flammation. It  is  also  often  found  in  connection  with  congenital  dt'fects 
and  fissures  about  the  vulva,  with  inflammation  of  the  hymen,  or  with 
ulcers,  specific  or  otherwise,  about  the  vulva ;  or  it  may  frequently  be  asso- 
ciated with  gonorrhoeal  warts,  or  from  warts  resulting  from  along-standing 
discharge,  not  necessarily  of  a  gonorrhoeal  nature,  but  due  to  irritation  — 
such  as  occurs,  for  instance,  in  masturbators.  And.  lastly,  dyspareunia 
and  vaginismus  may  be  found  in  association  with  urethral  caruncle. 

M 


r62  SYSTE3I   OF  GYNECOLOGY 

Apart  from  these  causes  directly  connected  with  the  orilice  of  the 
vagina,  dyspareunia  sometimes  occurs  in  association  with  some  trouble  in 
the  immediate  neighbourhood,  such  as  a  rectal  fissure  or  piles.  Difficulty 
and  pain  in  coitus  are  present  in  some  cases  of  prolapsed  uterus ;  in  these 
cases,  if  the  uterus  be  outside,  sexual  intercourse  is  rendered  practically 
impossible,  but  pain  is  not  necessarily  present.  With  retroverted  and 
retroflexed  uterus  dyspareunia  is  apt  to  be  present ;  and  in  cases  where 
the  ovar}'-  is  prolapsed  and  congested  the  pain  is  often  severe.  In  in- 
flammatory conditions  of  the  pelvis,  whether  of  the  pelvic  peritoneum 
(perimetritis)  or  of  the  cellular  tissue  (parametritis),  and  in  cases  of 
haematocele  and  hematoma,  which  become  secondarily  associated  with 
inflammatory  disease,  pain  in  sexual  intercourse  may  result ;  or  again, 
from  adhesions  between  the  tubes,  ovaries,  uterus,  intestine,  and  other 
parts  of  the  pelvis,  which  result  from  long-standing  inflammatory  mis- 
chief. Cysts  in  the  vaginal  wall,  though  rarely  of  considerable  size, 
occasionally  give  rise  to  the  difficulty.  Polypi  of  the  uterus  passing 
down  into  the  vagina,  and  fibroid  growths  becoming  impacted  in  the 
pelvis,  will  give  rise  to  difficulty  and  very  often  to  pain  in  coitus. 

Dysmenorrlice.a.  —  Pain  at  the  periods  may  have  been  present  from 
the  very  beginning  of  menstruation,  or  have  resulted  subsequently. 
The  division  iiito  primary  and  secondary  is  useful.  The  secondary  vari- 
ety is  very  often  of  an  inflammatory  character,  and  dates  either  from  a 
confinement  or  a  miscarriage.  In  inquiries  with  reference  to  dysmenor- 
rhoea  we  should  first  ascertain  where  the  pain  is  situated,  whether  in  the 
abdomen  or  in  the  back ;  and  if  in  the  abdomen,  whether  it  is  confined 
to  one  side  or  the  other,  or  extends  from  side  to  side ;  whether  it  radiates 
down  the  thighs,  or  extends  for  a  considerable  distance  over  the  abdomen. 
The  pain  sometimes  extends  as  high  as  the  mammary  region.  Next,  we 
should  ascertain  when  the  pain  begins,  whether  before  the  flow  or  with 
the  flow ;  and  if  before  the  flow,  how  long  before.  Usually  it  will  be 
found  that  it  commences  a  few  hours  or  a  day  or  two  previous  to  the 
onset  of  the  period;  and  in  cases  of  severe  dysmenorrhoea  the  pain 
may  come  on  even  so  long  as  a  Aveek  before  the  period.  The  duration 
of  the  pain  is  variable.  In  some  cases  the  pain  which  has  begun 
before  the  period  will  cease  when  the  flow  begins  or  is  freely  estab- 
lished. It  may  cease  after  the  first  day,  but  sometimes  in  severe 
dysmenorrhoea  is  continued  for  two  or  three  days,  and  occasionally  to 
the  end  of  the  period ;  or  again  it  may  even  continue  after  the  flow 
has  stopped. 

With  the  view  of  ascertaining,  in  the  next  place,  the  amount  of  the 
pain,  we  should  inquire  whether  the  patient  has  to  lie  up  or  not  while  it 
lasts;  whether  she  is  incapacitated  from  following  her  usual  occupation. 
Some  patients  who  keep  about  will  tell  us  that  they  would  lie  up  if  their 
circumstances  permitted.  Others  will  tell  us  that  they  are  always 
obliged  to  take  to  bed  during  the  first  day  or  two  of  the  periods ;  others, 
again,  will  say  that  to  do  so  would  be  of  no  use,  the  pain  being  so  severe 
they  cannot  keep  quiet  and  have  to  roll  al)out  on  the  floor.     Such  facts 


DIAGNOSIS  IN  GYN.'ECOLOGY  163 

as  these  will  enable  us  to  judge  whether  the  pain  be  severe  or  not.  In 
eases  of  less  severity,  it  is  possible  to  judge  of  the  amount  of  the  pain 
by  the  patient's  answer  to  the  question  whether  any  particular  treatment 
has  been  found  efficacious  in  its  relief,  such  as  —  to  take  the  most  popu- 
lar—  hot  gin  and  water,  hot  ginger,  local  applications,  fomentations,  hot 
bricks  wrapped  up  in  flannel,  or  hot-water  bottles  ;  and,  finally,  whether 
they  have  been  under  medical  treatment  during  the  periods. 

The  causes  of  dysmenorrhoea  are  to  be  found  either  in  some  general 
condition  of  ill  health,  or  in  some  morbid  condition  of  the  pelvic  organs. 
Let  us  consider,  first,  those  general  conditions  which  occur  apart  from  the 
uterus  and  pelvic  organs.  A  very  common  example  of  general  ill  health, 
accompanied  by  severe  menstrual  pain,  takes  the  form  of  a  general 
neurosis,  the  patient  suffering  from  what  is  termed  spasmodic  dysmenor- 
rhoea. This  form  of  the  disease  is  always  primary  in  character,  begin- 
ning, as  a  rule,  with  the  first  period,  and  continuing  with  increasing 
intensity  as  time  goes  on.  In  cases  of  anaemia  and  chlorosis,  and  in 
cases  of  chronic  constipation,  dysmenorrhoea  of  some  severity  may  be 
present  without  recognisable  disease  of  the  uterus  or  pelvic  organs. 
In  cases  of  congestion  of  the  pelvic  organs,  by  whatever  cause  produced 
—  secondary,  it  may  be,  to  heart  or  liver  disease  —  and  in  cases  of  inflam- 
mation in  the  pelvis,  dysmenorrhoea  may  be  a  prominent  symptom.  But 
the  pain  in  these  cases  occurs  not,  as  a  rule,  during,  but  between 
the  periods.  The  loss  which  occurs  relieves  the  congestion,  and  to  some 
extent  diminishes  the  inflammatory  condition  by  depletion,  so  that 
as  soon  as  the  flow  is  freely  established  the  pain  from  Avhieh  the 
patient  had  previously  suffered  sometimes  ceases,  and  returns  when 
the  period  has  come  to  an  end. 

Certain  diseases  of  the  uterus  itself  are  likewise  apt  to  be  associated 
with  the  occurrence  of  pain  at  the  periods.  And  first  may  be  mentioned 
the  incompletely  developed  uterus,  the  uterus  being  smaller  than  it 
should  be ;  very  often  no  bigger  than  the  top  of  the  little  finger.  With 
it  incomplete  development  of  the  ovaries  is  likely  to  be  associated ; 
indeed,  these  organs  may  be  absent  altogether. 

A  small  congenitally  anteflexed  uterus  is  another  form  of  incomplete 
development  frequently  associated  Avitli  dysmenorrhoea.  A  still  more 
common  condition  takes  the  form  of  an  elongation  of  the  cervix  in  its 
vaginal  portion,  an  abnormity  known  as  conical  cervix,  and  usually 
associated  with  a  small  orifice  or  "  pin-hole  os." 

Fibroma  of  the  uterus  is  not  painful,  as  a  rule,  except  at  the  periods. 
During  the  active  congestion  which  accompanies  the  early  part  of  the 
periods  fibroids  often  give  rise  to  considerable  dysmenorrhoja. 

In  cases  of  displacement  of  the  uterus  dysmenorrhea  may  become  a 
prominent  symptom,  especially  when  the  uterus  becomes  retroverted  and 
retroflexed,  and  impacted  at  the  floor  of  the  pelvis  between  the  sacro- 
iiterine  ligaments.  There  the  congestion  in  the  fundus  becomes  very 
marked,  and  severe  pain  in  the  early  part  of  the  period  results. 

Membranous  dysmenorrho'a.  though  rare,  is  almost  invariably  asso- 


1 64  SYSTEM   OF   GYA\  ECO  LOGY 

ciated  with  severe  pain,  during  which  the  patient  passes  a  membrane 
either  as  a  cast  of  the  nterus  or  in  shreds. 

Menorrhagia  and  Metrorrhagia.  —  Menorrhagia  is  an  increase  in  the 
flow  at  the  periods,  and  takes  the  form  of  increased  duration  of  the 
flow,  shortening  of  tlie  interval  between  the  periods,  or  increased  daily 
loss.  Metrorrhagia  is  an  irregular  flow  between  the  periods.  These 
maladies  often  merge  one  into  the  other,  so  that  it  may  become  impos- 
sible to  draw  any  distinct  line  between  them.  Of  the  estimate  of  quan- 
tity I  have  already  spoken. 

The  colour  of  the  flow  varies  in  different  cases.  When  the  flow 
is  very  profuse  it  has  a  bright  hue.  In  other  cases  it  is  dark  in  colour, 
the  usual  colour  of  the  menstrual  discharge  ;  in  others,  again,  it  takes  on 
a  brownish  appearance,  especially  as  a  free  flow  is  beginning  to  clear  off. 
There  may  sometimes  be  a  mere  show ;  or,  on  the  ottier  hand,  the  loss 
may  take  the  character  of  a  pinkish  serous  discharge.  Occasionally,  if 
there  be  any  leucorrhceal  discharge  as  well,  streaks  of  blood  will  be  found 
in  association  with  it. 

General  Causes  of  Haemorrhage.  —  In  a  certain  number  of  cases  of 
anaemia  and  chlorosis,  in  contradistinction  to  the  usual  condition  of 
amenorrhoea,  menorrhagia  appears.  This  is  the  case  rather  in  the  severer 
forms  of  the  disease ;  indeed,  the  loss  tends  to  aggravate  the  disorder. 
In  congestive  conditions  of  the  heart  and  liver  menorrhagia  is  apt  to 
be  present,  and,  of  course,  metrorrhagia  too ;  for  owing  to  the  obstruction 
of  the  circulation  an  excessive  flow  is  apt  to  occur  not  only  at  the 
periods,  but  also  between  them.  This  loss  may  be  compared  with  the 
escape  from  a  safety-valve,  and  should  not  be  injudiciously  checked.  In 
some  cases  of  acute  specific  disease,  and  especially  in  those  associated 
with  hsemorrhagic  tendency  —  such  as  typhus  fever,  scarlet  fever,  small- 
pox, and,  to  a  less  extent,  measles  —  menorrhagia  is  apt  to  set  in  at  the 
beginning  of  the  fever.  Sometimes  it  becomes  marked  and  requires 
particular  treatment.  In  some  blood  diseases,  again,  such  as  purpura 
and  haemophilia,  an  increased  flow  at  the  periods  is  apt  to  occur. 

Local  Causes  of  Haemorrhage.  — From  these  general  causes  I  pass  next 
to  certain  conditions  in  the  pelvis  outside  the  uterus.  In  inflammatory 
conditions  in  the  pelvis  —  such  as  parametritis  and  perimetritis  —  menor- 
rhagia and  metrorrhagia  sometimes  occur.  These  cases  almost  come  into 
the  same  category  as  those  in  which  the  heart  and  liver  are  diseased ; 
for  in  many  of  them,  at  any  rate,  the  vessels  become  involved,  the  veins 
become  plugged,  and  so  the  return  of  the  blood  to  the  heart  is  interfered 
with.  The  loss  in  such  cases,  therefore,  unless  it  be  excessive,  has  a 
beneficial  tendency  by  depicting,  and  thus  relieving  the  intianuuatory 
condition. 

In  pelvic  h;x;matocele  and  pelvic  lujematoma  bleeding  is  a])t  to  take 
place.  The  usual  history  in  such  cases  is  that,  either  as  the  result  of  some 
excessive  work  undertaken  at  the  period,  or  of  a  chill  caught  after  the  flow 
has  begun,  the  discharge  suddenly  ceased,  but  reappeared  and  therciafter 
confiniK'd  for  a  h;iigfr  tiirie  than  it  should  do,  perhaps  for  a  fortnight. 


DIAGNOSIS  IN  GYNECOLOGY  165 

In  some  cases  of  ovarian  congestion  and  ovaritis  menorrhagia  and 
metrorrhagia  are  liable  to  ensue.  Especially  is  this  likely  to  occur  as 
the  result  of  too  frequent  sexual  intercourse  soon  after  marriage.  In 
ovarian  disease  proper  —  such  as  ovarian  cystoma  —  amenorrhoea  is  the 
rule ;  but  in  a  certain  number  of  cases  menorrhagia  and  metrorrhagia 
take  its  place.     The  same  remark  also  applies  to  cases  of  tubal  disease, 

—  hydrosalpinx,  hoematosalpinx,  and  pyosalpinx;  in  these,  though 
amenorrhoea  more  frequently  occurs,  menorrhagia  and  sometimes 
metrorrhagia  are  occasionally  present. 

The  abnormal  conditions  of  the  uterus  itself,  which  give  rise  to 
haemorrhage,  may  be  conveniently  divided  into  those  found  in  the  unim- 
pregnated  and  those  occurring  in  connection  with  child-bearing,  Avhether 
during  pregnancy  or  during  the  puerperium. 

In  cases  of  metritis,  with  disease  of  the  lining  membrane  of  the  uterus 

—  a  state  to  which  various  names,  such  as  fungous  and  villous  endome- 
tritis, have  been  given  —  hemorrhage  is  an  almost  constant  symptom; 
there  is  excessive  flow  at  the  periods,  and  very  often  a  loss  also  between 
the  periods ;  the  periods  come  on  too  frequently,  last  too  long,  and  the 
daily  loss  is  more  than  natural. 

In  cases  of  mucous  polypi  of  the  cervix,  again,  haemorrhage  is  by  no 
means  uncommon ;  and  with  this  I  ought  to  mention  a  condition  ante- 
cedent to  it,  namely,  the  thickening  of  the  mucous  membrane  of  the  cervix. 
Avith  proliferation  of  the  gland  tissue,  which  often  extends  to  the  vaginal 
portion,  and  produces  what  is  known  as  an  adenomatous  erosion.  This 
condition  gives  rise  not  only  to  excessive  haemorrhage  during  the  periods, 
but  also  very  frequently  to  haemorrhage  during  the  intermenstrual  time. 
It  may  be  particularly  noted  that  in  this  case  the  haemorrhage  —  a  metror- 
rhagia—  is  apt  to  folloAv  sexual  intercourse. 

Fibroids  or  myomas  in  the  uterus  are  frequently,  but  not  invariably 
associated  with  hasmorrhage.  Fibroids  projecting  on  the  peritoneal 
surface  —  that  is  to  say,  subperitoneal  fibroids  —  do  not  in  themselves 
cause  haemorrhage;  fibroids  in  the  v/all  of  the  uterus,  unless  they 
encroach  on  the  cavity  and  cause  it  to  enlarge,  do  not  give  rise  to 
haemorrhage  ;  but  haemorrhage  may  be  caused  by  fibroids  projecting  into 
the  uterine  cavity,  that  is  to  say,  by  submucous  fibroids ;  although  here 
again  bleeding  is  not  an  invariable  concomitant.  Fibroids,  however, 
when  they  become  polypoid,  almost  invariably  produce  ha?morrhage. 
It  must  be  remembered  that  fibroids  are  frequently  multiple;  and  that 
the  symptoms  may  be  due,  not  to  a  subperitoneal  fibroid  even  of  consider- 
able size,  but  to  a  smaller  mass  not  always  easily  recognised  beneath 
the  mucous  membrane.  The  haemorrhage  which  occurs  in  association 
with  fibroids  is  generally  menorrhagic  in  character,  although  it  occasion- 
ally occurs  in  the  intervals  between  the  courses,  and  is  often  ver}^  pro- 
fuse. It  is  probably  due  directly  to  an  unhealthy  condition  of  the  iiterine 
mucosa  induced  by  the  pi'esence  of  the  fibroid  mass. 

Malignant  disease  of  the  uterus,  whicli  generally  affects  the  cervix, 
is  a  potent  cause  of  h;emorrhage.     Especially  is  it  one  of  the  causes  of 


1 66  SYSTEM   OF  GYN^F.COLOGY 

hsemorrhage  occurring  at  the  climacteric.  Tlie  liEemorrliage  may  be 
menorrliagic,  but  it  is  more  frequently  metrorrhagic  in  character. 
From  the  cervix  the  malignant  disease  may  spread  to  the  body  of  the 
uterus.  Primary  cancer  of  the  body  of  the  uterus  is  also  associated 
with  haemorrhage,  but  it  is  a  comparatively  rare  condition,  and  the 
haemorrhage  when  it  occurs  is  not,  as  a  rule,  very  severe.  It  usually 
takes  the  character  of  a  watery  discharge  with  a  pinkish  tinge  rather 
than  of  a  severe  flow  of  blood  ;  though  in  certain  cases  even  of  primary 
cancer  of  the  body  severe  floodings  may  take  place.  In  sarcoma  of  the 
body  of  the  uterus  haemorrhage  is  apt  to  occur  and  to  constitute  a  promi- 
nent symptom. 

Senile  endometritis  is  another  condition  occasionally  met  with,  giving 
rise  to  haemorrhage  after  the  menopause.  The  distinction  between  senile 
endometritis  and  cancer  of  the  body  of  the  uterus  can,  as  a  rule,  only  be 
determined  by  exploration  of  the  cavity  of  the  organ. 

Special  Causes  of  Hasmorrhage  during  Pregnancy  and  after  Delivery. 
—  It  may  be  noted  that  occasionally  the  catamenia  persist  after  impreg- 
nation has  taken  place ;  the  periods  being  sometimes  continued  during 
the  first,  second,  and  third  months,  rarely  later  than  that.  It  is  often 
difficult  in  any  individual  case  to  say  whether  a  discharge  of  this  kind 
is  really  a  menstrual  period ;  but  usually,  if  it  preserve  the  same  char- 
acter as  a  period  and  come  on  regularly,  it  may  be  looked  upon  as  such. 
When,  however,  from  some  morbid  condition,  bleeding  occurs  during 
gestation,  the  loss  is  specially  apt  to  take  place  just  as  the  monthly 
cycles  come  round ;  consequently  an  impression  of  regular  periods  may 
be  produced  in  the  patient's  mind. 

Haemorrhage  in  association  with  gestation  may  be  symptomatic  of 
threatened  abortion,  of  bloody,  fleshy,  or  vesicular  mole,  or  of  ectopic 
gestation ;  and,  during  the  last  two  months  of  pregnancy,  of  accidental 
haemorrhage  or  of  placenta  preevia.  It  will  suffice  merely  to  mention 
these  matters  here. 

It  may  be  useful  to  bear  in  mind  that  the  other  causes  of  hsemorrhage 
occurring  during  pregnancy — haemorrhage,  that  is,  from  the  uterus  —  are 
generally  associated  either  with  cancer  of  the  cervix ;  or  with  adenoma  of 
the  cervix,  commonly  called  erosion ;  or  sometimes  with  mucous  polypi. 

Haemorrhages  occurring  shortly  after  delivery  do  not  fall  Avithin  the 
scope  of  this  volume.  Haemorrhage  setting  in  after  the  patient  has  left 
her  bed  and  the  lochia  have  ceased  may  depend  on  one  of  several 
conditions.  It  frequently  occurs  in  cases  of  sul)involution;  often  in 
association  with  inflammatory  disease,  or  with  the  retention  of  some 
j)ortion  either  of  placenta,  membrane,  or  blood-clot  within  the  uterus ;  or 
with  the  presence  of  a  fibroid  growth,  either  in  the  wall  or  beneath  the 
submucous  tissue  of  the  uterus,  or  of  a  polyjms.  Moreover,  the 
mucous  membrane  may  take  on  an  irregular,  villous,  or  fungous  char- 
acter, associated  in  many  cases  with  very  considerable  hiemorrhage. 

More  or  less  sharp  hynnorrhage  will  occur  in  some  cases  when  the 
patient  begins  to  get  up  ;  and  on  examination  it  will  be  found  that  the 


DIAGNOSIS  IN   GYNAECOLOGY  167 

uterus  is  prolapsed,  retroverted,  and  larger  than  it  should  be  from  conges- 
tion, and  sometimes  firmly  impacted  in  the  pelvis.  In  cases  of  inversion 
of  the  uterus  a  considerable  loss  often  takes  place,  with  leucorrhoeal 
discharge  in  the  intervals. 

Slight  haemorrhage  after  delivery  may  occur  from  incompletely  healed 
laceration  of  the  cervix,  or  from  erosion.  Cancerous  growths  of  the 
cervix  must  also  be  borne  in  mind  as  a  possible  cause  of  haemorrhage. 

Amenorrhcea.  —  During  pregnancy,  as  well  as  during  sTickling,  amen- 
orrhoea  is  the  rule.  But,  as  already  stated,  the  courses  sometimes  persist 
during  the  early  months  of  pregnancy,  and  even  later.  Many  women, 
too,  especially  those  of  rather  llorid  temperament,  will  continue  to  have 
the  periods  regularly  during  suckling,  and  that  even  from  a  month  after 
delivery.  It  is  necessary  to  bear  this  feature  in  mind,  because  patients 
are  apt  to  be  misled  in  consequence,  and  even  when  far  advanced  in 
pregnancy  will  persist  that  no  impregnation  can  have  taken  place.  A 
general  impression  also  prevails  that  suckling  prevents  impregnation.  To 
a  certain  extent  this  is  true,  but  by  no  means  invariably.  Women  who 
have  been  suckling  regularly  may  be  found  far  advanced  in  pregnancy, 
having  one  child  at  the  breast  while  carrying  another. 

When  the  menopause  is  artificially  induced,  as  by  the  removal  of  the 
ovaries,  for  fibroid  disease  of  the  uterus  or  other  such  reason,  amenorrhcea 
as  a  rule  results.  Occasionally  the  patient  will  have  one  period  after- 
wards, sometimes  two  or  three.  In  cases,  however,  where  the  periods 
continue  regularly  it  is  doubtful  whether  the  whole  of  both  ovaries  has 
been  removed ;  removal  of  one  ovary  does  not  stop  the  flow.  In  some 
cases  after  complete  removal  of  both  ovaries  an  irregular  loss  occurs, 
resulting  from  concomitant  disease  of  the  uterus  itself,  such  as  the 
presence  of  a  small  polypus,  mucous  or  otherwise,  in  the  cervix  or  body ; 
or  disease  of  the  lining  membrane  of  the  uterus. 

Among  the  general  causes  of  amenorrhcea  amemia  stands  first  in 
point  of  frequency. 

Amenorrhcea  is  also  apt  to  result  from  any  cause  of  malnutrition, 
particularly  acute  illness  or  chronic  wasting  disease :  it  may  be  found,  for 
example,  after  rheumatic  fever,  during  and  after  typhoid,  in  phthisis  and 
Bright's  disease,  and  so  forth. 

A  chill  taken  during  menstruation  will  sometimes  stop  the  periods 
without  producing  any  discoverable  lesion  of  the  pelvic  organs,  but  often 
inflammation  and  other  disorder  is  at  the  same  time  induced. 

In  cases  of  chronic  inflammation  of  the  ovaries  and  tubes,  in  ovarian 
cystoma,  in  hydrosalpinx,  hoematosalpinx,  and  pyosalpinx,  amenorrhcea 
is  sometimes  though  not  invariably  present.  In  some  cases  the  regularity 
of  the  periods  may  not  be  interfered  with,  and  in  others  menorrhagia 
takes  place. 

In  rudimentary  conditions  of  the  ovaries  and  uterus  primary 
amenorrhcea  is  frequently  present,  and,  if  not  absolute,  it  will  usually 
happen  that  the  periods  occur  at  considerable  intervals — five  or  six  weeks, 
perhaps  two  or  three  months  intervening  —  and  the  loss  is  very  slight,  a 


1 68  SyST£iV   OF  GYNECOLOGY 

mere  show  on  each  occasion.  But  here  again  amenori-ho?a  is  by  no 
means  invariable.  I  have  known  cases  of  small  uterus  and  ill-developed 
ovaries  with  riienorrhagia. 

Leucorrhcea.  —  In  making  inquiries  with  regard  to  leucorrhoea  we 
should  ascertain,  first  of  all,  the  character  of  the  discharge.  It  may  be 
white  or  colourless,  opaque  or  glairy  ;  that  is,  either  like  milk  or  like  the 
white  of  egg.  The  natural  discharge  from  the  cervix  is  glairy  and  mucoid, 
becoming  opaque  when  it  passes  into  the  vagina.  On  the  other  hand,  in 
disease  the  discharge  may  be  of  a  yellowish  or  creamy  colour ;  or  it  may 
be  greenish,  or  brown  and  mixed  with  blood.  With  a  view  to  ascertain 
the  extent  of  the  discharge  the  patient  may  be  asked  whether  it  is  such 
as  to  require  a  diaper.  The  answer  will  generally  afford  some  means  of 
ascertaining  its  amount.  Then  we  should  inquire  when  it  occurs — whether 
it  persists  during  the  whole  intermenstrual  period,  or  comes  on  just  before 
or  just  after  the  flow  —  and  when  it  is  of  greatest  intensity.  As  a  rule 
leucorrhoeal  discharges  are  most  marked  just  before  or  just  after  the 
menstrual  flow. 

The  causes  of  leucorrhoea  are  general  weakness,  antemia,  wasting 
diseases,  and  worms.  Thread-worms  in  children  are  especially  apt  to  be 
associated  with  considerable  leucorrhoeal  discharge.  Under  these  circum- 
stances the  mother  frequently  brings  the  child  to  the  doctor,  imagining, 
perhaps,  that  she  has  been  tampered  with.  We  should  look  out  for  worms 
in  such  cases,  or  for  the  vulvitis  which  in  children  follows  such  diseases 
as  measles,  scarlatina,  whooping-cough,  chicken-pox,  and  the  like. 

Leucorrhoea  may  be  the  result  of  vaginitis,  arising  either  from  the 
presence  of  foreign  bodies  in  the  vagina,  from  some  irritation  of  the 
vagina,  as  in  cases  of  masturbation,  or  from  the  presence  of  ill-fitting 
pessaries  or  pessaries  that  have  been  worn  for  a  considerable  time.  With 
vascular  caruncle  of  the  urethra  there  may  sometimes  be  a  little 
leucorrhoeal  discharge. 

Gonorrhoea  is  a  potent  cause  of  leucorrhoeal  discharge,  often  in  its 
worst  form ;  but  even  in  these  cases  the  discharge  is  not  necessarily 
profuse. 

Soft  chancres  about  the  vulva,  again,  are  frequently  associated  with 
a  certain  amount  of  leucorrhoeal  dischai-ge.  Tears  about  the  vulva,  too, 
such  as  occur  after  operations  or  after  delivery,  if  they  fail  to  heal  prop- 
erly, may  give  rise  to  a  leucorrhoeal  discharge. 

Erosions  of  the  cervix,  whether  merely  catarrhal  or  adenomatous,  are 
generally  accompanied  by  a  discharge  wliich,  as  it  pours  away  from  the 
cervix,  is  glairy  ;  but  it  becomes  opaque  on  reaching  the  vagina  unless  the 
quantity  be  great.    The  discharge  in  some  of  these  cases  in  very  profuse. 

Eversion  of  the  cervix,  generally  the  result  of  a  bilateral  laceration 
of  the  cervix  occurring  during  delivery,  is  attended  by  leucorrhoea. 

Leucorrhoea  is  also  to  be  found  in  cases  of  raucous  polypi  of  the 
cervix,  in  cases  of  cervical  catarrh,  in  cases  of  subinvolution  of  the 
uterus  occurring  after  delivery  or  miscai'riage,  in  cases  of  senile  cor- 
poreal endometritis,  in  disease  of  the  uterine  mucosa,  whetlier  associated 


DIAGNOSIS  IN   GYNECOLOGY  169 

with  submucous  fibroids  and  polypi  of  the  uterus  or  not,  in  cases  of 
cancer  of  the  uterus,  in  cases  of  chronic  inversion  of  the  uterus,  and, 
finally,  in  some  cases  of  pyosalpinx  and  pelvic  abscess,  or  suppurating 
cyst  in  the  pelvis,  when  the  discharge  finds  its  way  by  perforation 
through  the  uterus  or,  more  frequently,  through  the  vagina.  In  all 
such  cases  the  leucorrhoeal  discharge  is  liable  to  alternate  with  unusual 
losses  of  blood. 

Foetor  of  the  discharges  (which  necessarily  means  sapramic  decom- 
position) may  be  met  with  in  cases  of  threatened  miscarriage  and  of 
incomplete  abortion ;  in  cases  of  subinvolution  associated  witli  retained 
products  of  gestation ;  in  cases  of  severe  inflammatory  mischief,  such  as 
occurs  in  gonorrhoea,  and  particularly  when  an  abscess  has  opened  into 
the  canal;  in  cases  of  cancer;  in  cases  of  senile  endometritis;  and  in 
some  cases  of  submucous  fibroids  and  polypi  in  which  the  tumour  has 
sloughed.  The  discharge,  however,  may  take  on  an  offensive  odour 
under  other  conditions,  —  as,  for  example,  with  mere  rents  about  the 
vulva,  siich  as  occur  after  delivery,  —  and  in  some  cases  of  cervical 
erosion  and  eversion. 

Local  Swellings  or  Tumours.  —  We  should  ascertain  from  the  patient 
if  she  has  noticed  any  swelling  either  in  the  abdomen  or  privates ;  when 
the  swelling  first  appeared,  and  Avhether  it  be  persistent  or  variable  in  char- 
acter. We  should  inquire  also  the  site  where  it  was  first  noticed,  and  the 
direction  in  which  it  has  grown.  In  order  to  ascertain  from  the  patient 
whether  any  considerable  enlargement  of  the  abdomen  has  really  taken 
place,  it  is  well  to  ask  whether  she  has  had  to  let  out  her  clothes. 
Uterine  enlargements  commence  at  or  near  the  middle  line;  ovarian 
tumours  are  usually  noticed  first  at  one  side  or  the  other,  and  only  after 
a  time,  as  increase  takes  place,  do  they  extend  upwards  and  towards  the 
middle  line.  Distensions  of  the  tubes  and  inflammatory  effusions  are 
usually  found  near  the  groins,  and  thence  extend  into  the  iliac  fossae. 

Among  unilateral  swellings  about  the  vulva  may  be  mentioned 
abscess,  cyst,  varicose  enlargement,  inflammatory  induration  of  the 
labium,  and  possibly  hernia.  Protrusions  in  the  middle  line  are 
commonly  urethral  caruncle,  cystocele,  rectocele,  or  prolapsed  and  pro- 
cident  uterus. 

The  various  tumours  met  with  in  the  abdomen  and  pelvis  will  be 
enumerated  later  in  dealing  with  the  abdominal  and  vaginal  examination 
of  the  patient. 

Urinarij  Si/vipfoms.  —  We  should  note  the  character  of  the  pain,  if 
present,  and  the  time  at  Avhich  it  occurs  —  Avhether  during  micturition, 
previous  to  micturition,  or  following  micturition.  We  should  note  also 
the  frequency  of  micturition,  and  whether  it  takes  place  most  frequently 
at  night  so  as  to  disturb  the  patient's  rest,  or  during  the  day  when  she 
is  up  and  about;  or  if,  on  the  other  hand,  there  be  difficulty  in  getting 
the  water  to  pass,  or  such  inability  as  to  necessitate  the  use  of  the 
catheter.  Or,  again,  the  Avater  may  constantly  run  away;  or  be  passed 
involuntarilv  on  coughing  or  strainincr. 


I70  SYSTEM   OF  GYNECOLOGY 

The  character  of  the  urine  may  be  partly  learned  from  the  patient, 
and  will  probably  also  be  tested.  Pus,  lalood,  or  mucus  from  the 
vagina  may  be  found  mixed  with  it,  and,  in  order  to  obtain  a  sample 
uncontaminated,  it  may  be  advisable  to  pass  the  catheter.  Many 
general  diseases — such  as  diabetes,  insipidus,  and  mellitus;  hysteria; 
nocturnal  incontinence  —  may  give  rise  to  one  or  other  of  the  foregoing 
symptoms ;  or  affections  of  the  urinary  organs  not  a  part  of  the  special 
diseases  of  women  —  nephritis,  for  instance,  Avhether  acute  or  chronic; 
calculus  either  in  the  kidney,  ureter,  or  bladder;  pyelitis;  cystitis;  or 
displaced  kidney  —  may  interfere  with  the  urinary  function. 

Associated  with  disturbance  of  micturition  may  be  mentioned  cysto- 
cele  with  or  without  prolapse  of  the  uterus  ;  until  the  swelling  be  pressed 
up  this  frequently  causes  difficulty  and  delay  in  passing  water.  In 
cases  of  vesico-urinary  and  vagino-urinary  fistulas,  constant  or  nearly 
constant  dribbling  away  of  the  urine  takes  place.  Vascular  caruncle 
frequently  gives  rise  to  pain  in  passing  the  water.  In  vulvitis,  such  as 
sometimes  affects  weakly  children ;  in  vaginitis,  from  whatever  cause 

—  such  as  foreign  bodies,  ill-fitting  pessaries,  and  so  forth,  or  resulting 
from  general  weakness ;  and  in  cases  of  gonorrhcBa,  the  urethra  is  often 
implicated ;  and  pain  in  passing  water  is  complained  of  as  well  as  difficult}' 
in  getting  the  water  to  pass :  occasionally  there  is  retention. 

In  cases  of  polypi  from  the  uterus  coming  down  into  the  vagina, 
and  of  various  tumours  (especially  when  impacted  in  the  pelvis),  such  as 
fibroids,  ovarian  tumours,  parovarian  tumours,  dermoid  tumours  of  the 
ovary,  tubal  distensions,  hydrosalpinx,  hsematosalpinx,  and  pyosalpinx, 
ectopic  gestations,  and  retroverted  gravid  uterus,  micturition  may  be 
interfered  with ;  and  incontinence,  excessive  frequency  of  micturition, 
pain  in  passing  water,  or  retention  may  take  place.  The  same  may 
occur  in  advanced  cases  of  cancer,  of  sarcoma  of  the  uterus,  and  of  in- 
flammatory conditions  in  the  pelvis,  such  as  perimetritis,  and  parametritis, 
hsematocele,  haematoma,  and  pelvic  abscess.  Finally,  unusual  frequency 
of  micturition  may  be  reckoned  as  one  of  the  earliest  signs  of  pregnancy. 

Intestinal  Symptoms.  —  We  should  ascertain  the  frequency  with  Avliich 
the  bowels  are  relieved,  and  if  def'secation  be  painful,  difficult,  or  asso- 
ciated with  tenesmus.  If  constipation  be  a  prominent  feature  the 
effects  of  remedies  often  afford  us  some  information.  The  presence  of 
blood,  mucus,  or  pus  in  the  stools  should  be  noted.  We  should  next  note 
the  condition  of  the  tongue,  and  inquire  as  to  the  appetite  and  digestion 

—  whether  nausea  or  vomiting  be  present,  and  if  so,  the  time  at  which 
they  occur,  and  the  character  of  the  vomit;  facts  which  may  have  an 
important  bearing  on  the  question  of  gestation. 

It  may  be  remarked  that  these  intestinal  troubles,  like  the  urinary,  are 
not  by  any  means  necessarily  associated  with  disease  in  the  pelvis,  but 
more  often  result  from  general  disease,  such  as  chronic  constipation ;  or 
from  disease  of  the  lower  bowel,  such  as  haemorrhoids,  stricture,  malignant 
disease,  and  fistula  in  ano.  But  among  other  causes  may  be  instanced 
recto-vaginal  fistula,  rectocele  with  i)r()l;i,])S(!  of  the  posterior  vaginal  wall. 


DIAGNOSIS  IN   GYNECOLOGY 


prolapse  of  the  uterus  and  procideut  uterus,  tumours  impacted  in  the  pel- 
vis, cancer,  sarcoma,  and  filDroids  (jf  the  uterus.  Again  in  inflammatory 
swellings,  such  as  perimetritis  and  parametritis,  heematoma,  htematocele, 
and  pelvic  abscess,  the  inflammatory  process  often  involves  the  mucous 
membrane  of  the  bowel,  and  sometimes  leads  to  the  passage  of  Ijlood  and 
mucus.  Pain  and  difficulty  in  deftecation  are  apt  to  be  present  when  the 
ovaries  and  tubes  are  prolapsed,  and  the  uterus  retroflexed  or  retroverted ; 
for,  if  the  bowels  become  constipated,  the  attempts  at  defa3cation  force 
the  faeces  down  above  the  misplaced  mass,  which  may  act  as  a  sort  of 
ball-valve  on  the  rectum,  and  increase  the  difficulty. 

General  Symptoms.  —  Anaemia,  wasting,  fever,  and  so  forth,  will 
generally  come  to  light  with  the  other  and  more  special  symptoms  of 
which  the  patient  has  already  complained. 

Previous  Tre.atment.  —  Finally,  we  must  ascertain  and  note  what 
previous  treatment,  if  any,  has  been  adopted,  how  long  it  has  been 
carried  out,  and  with  what  result.  We  should  note  particularly 
whether  the  patient  had  been  confined  to  bed,  and  for  what  length  of 
time ;  and  what  local  measures,  if  any,  have  been  adopted,  either  in 
the  form  of  applications,  such  as  douches,  tampons,  pessaries,  or  of 
operative  procedures. 

The  physical  examination  of  the  patient.  —  In  conducting  the 
physical  examination  of  the  patient  attention  will  first  be  directed  to 
the  abdomen;  afterwards  to  the  internal  examination. 

Examination  of  the  Abdomen. — We  should  note  first  the  size  and 
shape  of  the  abdomen.  If  it  be  enlarged  measurements  must  be  taken. 
These  are  from  the  umbilicus  to  the  xiphi-sternal  articulation  ;  from  the 
umbilicus  to  the  top  of  the  S3nnphysis;  from  the  umbilicus  to  the  ante- 
rior superior  spines,  right  and  left;  the  girth  at  the  umbilicus,  and  in 
great  enlargements  the  greatest  girth. 

In  the  next  place  the  umbilicus  is  to  be  observed,  -whether  it  be 
protruded  or  depressed :  it  protrudes  when  there  is  free  fluid  in  the 
abdomen  and  in  cases  of  umbilical  hernia;  it  is  unusuall}'  depressed 
when  there  is  m\ich  fat  on  the  abdominal  wall. 

A  note  also  should  be  made  of  the  condition  of  the  linea  alba,  the 
marked  pigmentation  of  which,  at  any  rate  in  the  lower  part,  is  often 
an  indication  of  pregnancy. 

The  existence  of  striae  or  skin  cracks  on  the  external  surface  of  the 
abdomen  is  to  be  noted;  their  number,  their  size,  their  colour,  their 
position,  and  the  direction  in  which  they  run.  Skin  cracks  are  an 
indication  that  the  abdomen  is  or  has  been  distended  ;  not  necessarily  by 
pregnancy,  though  that  is  the  most  common  cause :  ascites  and  other  like 
distensions  will  produce  them.  The  colour  of  these  cracks  will  vary  with 
the  lapse  of  time  since  the  distension  occurred ;  fresh  skin  cracks  are 
usually  pinkish  in  colour ;  old  ones  are  whitish,  or,  if  they  have  become 
redistended,  acquire  a  bluish  tinge.  Their  number  and  size  will  vary 
not  only  according  to  the  amount  of  the  distension,  but  also  in  individ- 
ual cases.     Some  Avomen  pass  through  full  term  pregnancies,  and  have 


SYSTEM   OF  GYNAECOLOGY 


not  a  single  stria  left  to  tell  the  story ;  in  others  the  abdomen  may  be 
scored  by  strii»  before  the  mid-term  of  pregnancy  is  reached. 

The  thickness  of  the  abdominal  walls  varies  in  the  main  with  the 
amount  of  their  adipose  tissue.  In  Avomen  wlio  have  not  had  children 
they  are  often  extremely  rigid,  especially  in  neurotic  subjects  ;  whereas 
in  women  in  whom  the  abdomen  has  been  distended,  or  who  are  generally 
lax  of  tissue,  the  walls  may  be  so  exceedingly  thin  and  loose  that  the  hand 
may  sink  deeply  enough  on  the  abdomen  between  the  separated  recti  for 
the  promontory  of  the  sacrum  to  be  felt ;  and,  perhaps,  the  brim  of  the 
pelvis  may  be  mapped  out  through  the  anterior  abdominal  wall.  Any 
hernial  protrusion  on  the  abdominal  wall,  whether  at  the  umbilicus  or  in 
the  groin,  should  be  duly  noted ;  and  likewise  any  considerable  tender- 
ness or  resistance  in  the  abdominal  walls.  Neurotic  patients  under 
manipulation  are  very  apt  to  contract  the  walls  of  the  abdomen ;  but  in 
these  patients  the  resistance  is  general  over  the  abdomen,  and  not  limited 
to  the  lower  part  or  to  one  side,  as  is  usual  in  pelvic  disease. 

Abdominal  Enlargements.  —  The  main  causes  of  enlargement,  apart 
from  distinct  tumours  in  the  abdomen,  are  the  following :  — 

i.  General  obesity,  a  thick  adipose  condition  of  the  abdominal  wall, 
associated  with  a  large  deposit  of  fat  in  the  omentum  and  other  parts  of 
the  abdomen  beneath  the  peritoneum.  This  deposit  of  fat  often  occurs 
about  the  menopause.  The  abdominal  wall  may  be  increased  to  some 
four  or  five  inches  in  thickness,  a  state  of  matters  which  very  much 
interferes  with  any  examination  of  the  deeper  structures  of  the  abdomen. 

ii.  Flatulence  often  produces  general  enlargement  of  the  abdomen, 
and  likewise  interferes  with  examination.  It  is  associated  with  a  tym- 
panitic note  on  percussion.  In  some  women  enormous  distension  is  thus 
produced.  In  young  girls,  also,  considerable  distension  of  a  more  local- 
ised nature  often  gives  rise  to  the  impression  of  pregnancy ;  but  here, 
again,  the  tympanitic  note  on  percussion  is  distinctive  enough:  under 
chloroform  such  swellings  disappear. 

iii.  General  enlargement  of  the  abdomen,  due  to  fluid  accumulation, 
is  accompanied  by  dulness  on  percussion,  as  in  ascites  associated  with 
disease  of  the  heart  or  liver.  The  effusion  may  be  serous,  fibrinous, 
purulent,  or  hsemorrhagic. 

iv.  Occasionally  a  distinct  tumour  of  the  abdominal  wall  itself  may 
be  met  with.  I  have  seen  a  lipoma  which,  in  its  position  at  any  rate, 
very  closely  simulated  a  small  ovarian  tumour  —  for  which,  indeed,  it 
had  been  mistaken ;  but  careful  examination  showed  that  it  was  situ- 
ated in  the  a])d(jmiiial  wall  and  not  beneath  it. 

lat/ra-ahdominal  Tumours.  —  If  a  tumour  Ije  found  in  the  abdomen 
it  is  important  to  learn  when  the  swelling  was  first  noticed,  and  whether 
attention  was  drawn  to  it  by  pain  or  by  the  increase  of  the  abdomen. 
We  must  also  ascertain  at  what  point  it  was  first  observed,  whether  in 
the  upper  or  lower  part  of  tlie  aljdomen,  or  to  one  side  or  the  other ; 
the  dire(;tion  of  its  subsequent  growth;  its  rate  of  progress,  and 
whether  its  growth  has  l^een  steady  or  variable  in  rate. 


DIAGNOSIS  IN  GYNECOLOGY 


17: 


The  tumour  may  appear  to  be  rising  out  of  the  pelvis  in  the  middle 
line,  or  to  one  side  of  it ;  to  spring  from  the  lumbar  region,  or  from  the 
upper  part  of  the  abdomen  under  the  ribs.  The  longest  and  shortest 
measurement  of  the  tumour  must  be  noted;  its  shape  and  outline, 
whether  regular  or  irregular,  or  ill-defined;  its  consistence,  whether  it 
be  hard,  as  is  usual  in  fibroids,  or  soft,  as  are  most  ovarian  swellings ; 
whether  fluctuation  be  present  or  not,  and  if  present,  whether  the  fluid 
thrill  is  conducted  equally  in  all  directions.  The  mobility  of  the  tumour 
should  be  determined,  and  also  the  point  where  it  appears  to  be  attached. 
Occasionally  a  tumour  may  be  fairly  movable,  but  limited  by  adhesions 
in  one  or  more  directions  —  conditions  which  can  readily  be  estimated 
by  palpation  through  a  thin  and  lax  abdominal  wall.  In  endeavour- 
ing to  ascertain  the  mobility  of  the  tumour  one  may  notice  a  distinct 
crepitant  feeling  transmitted  to  the  hand,  which  usually  indicates  that 
some  inflammatory  mischief  has  produced  a  considerable  roughness  of 
the  tumour.  In  some  cases,  again,  under  favourable  conditions  of  the 
abdominal  wall,  a  pedicle  may  be  felt.  The  extent  of  the  area  of  dulness 
on  superficial  or  deep  percussion  may  or  may  not  correspond  with  the 
size  of  the  tumour.  The  stethoscope  will  enable  us  to  ascertain  whether 
there  be  any  sounds  about  the  tumour.  Apart  from  the  sounds  of  preg- 
nancy, in  some  cases  of  fibroid  tumour  a  sound  resembling  the  uterine 
bruit  of  gestation  may  be  heard;  or  if  the  surface  of  the  tumour  has 
been  roughened  by  inflammation,  friction  sounds  may  be  distinguished : 
in  many  cases  adventitious  sounds  are  conducted  from  the  aorta  or 
intestine. 

Pressure  on  the  main  venous  trunks  gives  rise,  in  some  cases,  to 
engorgement  of  the  veins  running  over  the  abdominal  wall ;  in  others 
to  varicose  veins  about  the  vulva,  thighs,  and  legs,  and  to  oedema  of  the 
lower  extremities. 

In  exceptional  cases,  as  a  means  of  diagnosis,  an  exploratory^  punct- 
ure of  the  tumour  may  be  allowed,  and  a  microscopical  examination  of 
the  fluid  made  in  order  to  ascertain  the  nature  of  the  swelling;  finally, 
exploratory  opening  of  the  abdomen  may  sometimes  be  called  for  to 
clear  up  aii  obscure  case. 

In  dealing  with  tumours  in  the  abdomen,  it  is  at  the  outset  advisable 
to  eliminate  the  possibility  of  pregnancy.  Before  proceeding,  therefore, 
to  a  differential  diagnosis  of  the  intra-abdominal  tumours  it  will  be 
advantageous  to  briefly  consider  the  indications  of  gestation. 

Diagnosis  of  Pregnancy.  —  The  shape  of  the  uterus  is  to  be  noted, 
whether  there  be  any  marked  obliquity  or  not ;  this,  if  present,  is 
usually  directed  to  the  right  side  of  the  abdomen.  On  palpation  the 
tumour  may  present  the  characters  of  a  gestation,  that  is  to  say,  of  fluid 
containing  a  solid  (the  foetus)  ;  with  easy  conditions  of  the  abdominal 
wall  as  regards  thickness  and  resistance,  it  may  be  possible  to  map  out 
the  position  of  the  back,  of  the  small  parts,  and  of  the  head  of  the  foetus ; 
and  to  feel  the  ftetal  movements.  In  some  cases  a  thrill  may  be  felt, 
though  this  is  by  no   means    common.     Contractions   of   the   uterine 


174  SYSTEM   OF  GYNyECOLOGY 


muscle  can  usually  be  induced,  and  are  an  important  diagnostic  sign, 
but  they  occur  also  in  fibroid  tumours.  At  the  sixth  month  of  preg- 
nancy the  fundus  of  the  uterus  reaches  to  about  the  level  of  the  navel ; 
at  the  fifth  month  it  is  about  half-way  between  the  navel  and  the  pubes  ; 
at  the  fourth  month  it  can  be  distinctly  felt  above  the  pubes ;  before 
that  period  it  is  not  easily  felt  above  the  brim.  At  the  seventh  month 
the  fundus  arrives  about  half-way  between  the  navel  and  the  ensiform 
cartilage ;  at  the  eighth  month  it  rises  to  the  level  of  the  xiphi-sternal 
articulation,  and  during  the  last  month,  as  the  foetal  head  comes  down 
in  the  pelvis,  it  sinks  a  little  again  in  the  abdomen.  But  it  must  be 
remembered  that  the  size  may  be  interfered  with  by  various  circum- 
stances. In  cases  of  multiple  pregnancy  —  twins  or  triplets  —  the  uterus 
at  any  given  stage  is  larger  than  in  a  normal  gestation :  this  is  also  the 
case  when  the  liquor  amnii  is  excessive,  and  in  hyclatidiform  mole.  The 
womb  is  smaller  than  usual  when  the  fcetus  is  abnormally  small;  when 
the  fcetus  dies,  prematurely  or  not,  or  is  interfered  with  in  its  develop- 
ment. ^Mien  the  contents  of  the  uterus  have  been  converted  into  a 
mole  the  organ  may  remain  for  a  long  time  almost  stationary  in  size. 
If,  on  auscultating  the  abdomen,  the  foetal  heart  is  heard  with  certainty, 
the  question  of  gestation  is  at  once  settled.  But  inability  to  hear  the 
heart  sounds  does  not  necessarily  contra-indicate  pregnancy,  for  this  sign 
is  naturally  absent  till  four  and  a  half  months  of  development  have  been 
attained :  and,  even  later,  it  cannot  always  be  heard  even  though  the 
foetus  be  alive.  By  observing  the  rhythm  of  the  foetal  heart,  and  at  the 
same  time  counting  the  rate  of  the  maternal  pulse,  the  possible  error  of 
mistaking  conducted  sounds  from  the  mother's  arteries  may  be  avoided. 
While  listening  to  the  foetal  heart,  it  is  often  possible,  with  the  hand 
on  the  other  side  of  the  abdomen,  to  feel  the  foetal  movements  quite 
distinctly ;  and  also,  perhaps,  contractions  of  the  uterine  muscle,  induced 
by  the  yjressure  of  the  stethoscope  :  both  of  these  signs  are  valuable  indi- 
cations of  pregnancy.  In  some  cases,  though  not  often,  one  may  light 
upon  an  umbilical  bruit,  a  sound  produced  by  the  pressure  of  the  steth- 
oscope on  the  umbilical  cord ;  it  is  synchronous  with  the  fostal  pulse, 
not  with  the  maternal.  Much  more  frequently  the  uterine  bruit  is 
heard,  a  sound  which  is  said  to  be  produced  in  the  large  sinuses  of  the 
uterus ;  this  bruit  is  synchronous  with  the  maternal  pulse.  The  uterine 
bruit  varies  much  in  different  cases,  and  in  its  characters;  it  may  vary 
even  in  the  same  case  at  different  times.  Sometimes  it  is  a  soft  mur- 
mur ;  sometimes  its  note  is  almost  hard  and  shrill ;  it  varies  from  time 
to  time  in  intensity  and  pitch,  and  in  the  position  in  wliich  it  is  heard. 
It  may  be  taken  as  diagnostic  of  the  uterine  character  of  the  tumour, 
but  not  necessarily  of  pregnancy;  for  it  is  som(itimes  hwird  in  cases  of 
uterine  fibroid. 

If  the  uterus  is  regulai'ly  enlarged,  if  no  indication  of  disease  be 
present,  and  if  tlie  uterus  corresponds  in  size  witli  what  might  be  ex- 
pected, the  diagnosis  of  gestation  is  usually  warranted,  even  in  the  early 
montlis  lif'.fore  the  advent  of  any  certain  indication.     But  when  compli- 


DIAGNOSIS  IN  GYNECOLOGY  175 

cations  are  present ;  or  the  history  is  misleading,  as  in  ectopic  ges- 
tation ;  or  unreliable,  as  when  the  patient  has  reason  to  conceal  the 
event,  it  is  well  to  withhold  an  opinion  until  some  certain  sign  appears. 
In  doubtful  cases  some  evidence  may  also  be  derived  from  the  breasts. 
The  breasts  usually  become  distended  and  enlarged  before  the  mid-period 
of  pregnancy  is  reached ;  the  nipples  and  the  areolae  surrounding  them 
become  more  prominent;  the  follicles  which  they  contain  stand  up  from 
the  surface ;  and  the  pigmentation,  especially  in  dark-complexioned  sul)- 
jects,  becomes  augmented,  and  spreads  beyond  the  true  areolae  so  as  to 
form  a  darkened  area,  with  small  spots  upon  it  devoid  of  pigment:  this 
is  exceedingly  characteristic  of  pregnancy,  though  not  absolutely  diag- 
nostic of  it,  for  similar  pigmentation  is  occasionally  observed  in  cases 
of  fibroid  tumours  of  the  uterus  and  of  ovarian  cystoma. 

Further,  fluid  may  exude  from  the  nipple  on  pressing  the  breasts. 
Though  the  pigmentation  and  secretion  afford  presumptive  evidence  of 
pregnancy,  it  must  be  borne  in  mind  that  these  signs  are  of  little  or  no 
value  after  the  first  pregnancy,  for  they  persist  after  delivery. 

The  striae  of  distension  on  the  breasts  rarely  occur  except  as  the 
result  of  engorgement  during  lactation. 

It  is  rare  for  an  abscess  to  form  in  the  breasts  except  after  child-birth 
or  miscarriage,  so  that  the  mark  left  by  an  abscess  is  also  fairly 
presumptive  evidence  of  past  gestation. 

Before  passing  on  to  speak  of  the  various  tumours  found  in  the 
abdomen  it  will  be  advisable  to  anticipate  somewhat,  by  referring  also 
to  the  internal  examination  in  cases  of  pregnancy.  If  the  patient  be 
pregnant,  the  following  points  may  be  noted  in  making  the  internal 
examination :  — 

The  cervical  canal  is  often  patulous  during  the  fifth,  sixth,  and 
seventh,  and  even  during  the  eighth  month  of  gestation  ;  but  it  closes  as 
the  time  of  delivery  approaches,  and  before  the  dilatation  proper  to 
labour  begins.  Its  size,  its  dilatability,  and  its  length  should  be  noted. 
The  cervix  becomes  thickened  and  softened  during  gestation,  and  during 
the  last  three  months  of  pregnancy  it  apparently  becomes  draAvn  up  out 
of  the  vagina. 

If  the  cervix  is  sufficiently  dilated,  it  may  be  possible  to  feel  the 
membranes  within  it,  or  possibly  the  placenta  in  cases  of  placenta  praevia, 
or  blood-clot  if  haemorrhage  have  occurred.  Blood-clot  may  be  distin- 
guished from  placenta  or  membrane  by  its  vanishing  luider  pressure  of 
the  finger  and  thumb  ;  membrane  or  placental  tissue  will  not  entirely  give 
way,  or  if  doubt  still  remain  the  mass  may  be  removed  for  examination. 

Through  the  cervix  it  may  be  possible  to  distinguish  the  presenting 
part  of  a  foetus  ;  but  more  frequently  its  presence  may  be  ascertained 
by  pressure  through  the  anterior  vaginal  wall  in  front  of  the  cervix. 
During  the  mid-period  of  gestation  ballotement  can  be  practised,  and,  if 
obtained,  it  forms  a  valuable  additional  indication  of  pregnancy. 

Abdominal  tnvionrs,  other  than  pregnane;/,  may  be  met  with  in  the 
abdomen.     Tumours   of    the    abdomen    beginning    above   and   coming 


176  SYSTEM  OF  GYNECOLOGY 

do-mi  from  under  the  ribs,  thoiigh  they  may  be  met  with  among 
gynaecological  patients,  do  not  properly  fall  within  that  category, 
except  as  a  matter  of  coincidence.  Of  such,  for  instance,  are  enlarge- 
ments of  the  liver  and  gall-bladder,  of  the  spleen,  and  of  the  stomach. 
Other  tumours  of  the  abdomen  take  their  origin  very  variously; 
as,  for  instance,  cancer  of  the  bowel,  feecal  accumulations,  localised 
peritonitis  with  effusion,  adhesions  the  result  of  peritonitis  (which 
I  mention  here  because  the  impression  of  a  very  distinct  tumour 
is  often  conveyed  by  such  adhesions),  omental  cysts,  hydatids,  and 
tumours  of  retroperitoneal  origin.  Tumours  of  the  kidney  beginning  in 
one  or  other  lumbar  region  frequently  find  their  way  to  the  brim  of  the 
pelvis;  or,  at  any  rate,  into  the  iliac  fossa.  An  abnormally  mobile  or 
wandering  kidney  is  frequently  observed  among  gynsecological  patients, 
for  the  simple  reason  that  this  condition,  which  is  more  common  on  the 
right  than  on  the  left  side,  is  usually  associated  with  a  general  laxity 
of  the  patient's  parts,  and  with  displacement  of  the  uterus  or  of  the 
ovaries. 

Tumours  beginning  below  may  be  uterine,  tubal,  ovarian,  or  para- 
metric in  origin.  A  full  bladder  should  invariably  be  reduced,  in  any 
doubtful  case  of  abdominal  tumour,  by  passing  a  catheter.  It  is  not 
sufficient  to  rest  satisfied  with  the  patient's  statement  that  urine  has  been 
passed  recently ;  because,  when  the  bladder  is  full,  though  micturition  be 
frequent,  the  amount  passed  is  small,  and  of  ten  consists  merely  of  overflow. 

Of  the  various  uterine  enlargements  some  preserve  the  natural 
contour  of  the  uterus,  others  are  irregular  in  shape.  Among  the 
regular  enlargements  may  be  reckoned  gestation ;  hydatidiform,  blood, 
and  fleshy  mole  ;  an  abnormal  enlargement  of  the  uterus  remaining 
after  delivery,  under  the  general  term  of  subinvolution ;  metritis  ;  pyo- 
metra,  and  heematometra.  Among  the  irregular  enlargements  may  be 
instanced  fibroid  tumours  of  the  uterus —  subperitoneal,  interstitial,  sub- 
mucous, or  polypoid ;  and  malignant  disease,  cancer,  and  sarcoma. 

Enlargements  of  the  tubes,  so  great  as  to  cause  abdominal  swelling, 
may  be  due  to  tubal  gestation,  which  often  ruptures  and  spreads  into  the 
broad  ligament,  or  into  the  abdominal  cavity;  hydrosalpinx;  pyosalpinx, 
whether  gonorrhoeal  or  septic ;  liEematosalpinx,  which  is  often  associated 
with  tiiljal  gestation,  or  produced  by  some  interference  with  the  due 
flow  of  blood  during  a  menstrual  period. 

Enlargements  of  the  ovary  may  be  cystic  or  solid.  Ovarian  cystoma 
is  the  most  common  form  of  ovarian  tumour.  It  is  frequently  multi- 
locular,  and  may  have  undergone  change ;  especially  from  congestion  due 
to  impaction  of  the  tumour,  or  twisting  of  the  pedicle  ;  and  inflammatory 
mischief  may  alter  the  character  of  the  fluid  to  blood  or  pus.  Der- 
moid tumours  of  the  ovary  frequently  occur  in  young  subjects,  and  are 
associated  with  the  formation  of  dermoid  structures,  such  as  bone,  teeth, 
hair,  skin  ;  these,  if  loft  untreated,  frequently  suppurate  and  discharge 
through  the  bladder,  vagina,  or  elsewliere.  Fibroma  of  the  ovary  and 
malignant  disease  of  the  ovary,  giving  rise  to  solid  tumours,  are  rare 


DIAGNOSIS  IX   GYNECOLOGY  177 

conditions.  Papilloma,  a  semi-malignant  disease  of  the  ovary,  is  apt  to 
find  its  way  through  the  surface  and  give  rise  to  deposits  associated  with 
the  presence  of  a  considerable  amount  of  free  fluid,  often  blood,  in  the 
abdominal  cavity. 

Parovarian  cysts  are  nearly  always  unilocular  and  contain  clear  fluid  ; 
otherwise  they  have  much  the  physical  characters  of  ovarian  cystoma. 

Local  effusions  of  serum,  pus,  or  blood  into  the  cellular  tissue  of  the 
pelvis  sometimes  spread  beyond  the  pelvic  region  into  the  abdomen 
beneath  the  peritoneum ;  and  find  their  way  to  the  abdominal  wall,  into 
the  groin,  behind  to  the  region  of  the  kidney,  or  to  the  buttocks  and 
vulva.  Similar  localised  effusions  into  the  pouch  of  Douglas  frequently 
extend  upwards  into  the  abdomen,  but  are  there  usually  limited  by 
matting  together  of  the  intestines. 

Among  abdominal  tumours  may  be  included  pelvic  adhesions,  which, 
by  the  matting  together  of  the  intestines,  frequently  give  rise  to  the 
impression  of  a  very  distinct  swelling  over  which  a  certain  amount  of 
resonance  can  usually  be  obtained. 

Examination  by  the  Vagina.  —  In  making  the  vaginal  examination 
it  is  advisal)le  to  deal  first  with  the  external  parts. 

Any  signs  of  irritation  on  the  skin,  such  as  redness,  inflammation,  or 
excoriations,  will  be  noted.  In  some  cases,  in  consequence  of  irritation, 
an  eruption,  usually  of  an  eczematous  character,  appears.  The  condi- 
tions under  which  this  is  found  are  usually  such  as  to  give  rise  to  an 
irritating  discharge,  as  in  cancer  of  the  cervix  or  body  of  the  uterus,  in 
sloughing  fibroids,  and  in  some  other  conditions  which  have  already 
been  mentioned,  such  as  erosions  ;  and  in  cases  of  gonorrhoea  and  severe 
vaginitis,  not  necessarily  of  a  local  specific  character.  Signs  of  irri- 
tation may  also  be  present  in  cases  of  masturbation ;  or  again,  when 
the  uterus  is  procident,  and  the  vaginal  walls,  thrust  outside,  are  irritated 
by  friction.  In  certain  cases  also  of  urethral  caruncle  irritation  is  set 
up ;  and,  finally,  in  diabetes  the  irritation  by  the  decomposing  sugar 
produces  considerable  irritation,  and  even  an  intractable  form  of  eczema. 

The  labia  majora  and  minora  may  be  hypertrophied.  In  patients 
subjected  to  the  above-mentioned  sources  of  irritation  more  or  less 
hypertrophy  often  occurs. 

The  clitoris,  too,  is  a  structure  which  varies  considerably  in  size,  and 
is,  in  some  cases,  hypertrophied. 

T7te  orifice  of  the  tirethra  may  show  signs  of  irritation,  more  espe- 
cially where  that  irritation  is  associated  with  pain  in  passing  Avater. 

In  examining  the  vulva,  its  size,  the  colour  of  the  surface,  the  pres- 
ence of  varicose  veins  or  of  ulcers  on  the  surface,  of  abscesses  or  cysts 
in  the  deeper  structures,  should  be  noted ;  and  also  whether  there  be  n 
discharge  bathing  its  surface,  or  signs  of  chronic  irritation  about  the 
parts,  as  is  frequently  evidenced  by  the  presence  of  small  warts.  Ex- 
pansion of  the  vulva  results  from  child-bearing,  especially  where  tlio 
woman  has  had  many  children,  and  in  its  more  marked  forms  from 
prolapse  of  the  vaginal  walls  and  falling  of  the  womb  ;  it  is  especially 


,78  SYSTEM   OF  GYNECOLOGY 


prone  to  occur  when  not  only  the  parts  in  the  pelvis,  but  the  tissues 
generally  are  wanting  in  tone.  On  the  other  hand,  the  vaginal  entrance 
may  be  smaller  than  usual  from  congenital  causes ;  or  from  spasm,  as 
in  vaginismus. 

The  colour  of  the  mucous  membrane  will  indicate  congestion,  either 
active  or  passive,  or  inflammation.  In  congestion  it  takes  on  a  sort  of 
peach  bloom  hue,  or  varies  from  that  to  purple,  as  in  the  case  of  pregnancy, 
and  of  some  tumours  in  the  pelvis,  particularly  fibroid  tumours ;  this 
change  may  occur  also  in  cases  of  heart  and  liver  disease.  In  inflam- 
matory conditions  the  redness  is  often  associated  with  much  swelling 
of  the  tissues.  Varicose  veins  are  specially  apt  to  appear  during  preg- 
nancy, from  the  pressure  of  tumours  in  the  pelvis  or  abdomen,  or  from 
some  general  condition  associated  with  deficient  return  of  blood  to  the 
heart,  such  as  takes  place  in  disease  of  the  heart  or  liver. 

Various  forms  of  ulcer  may  be  met  with  about  the  vulva.  Simple 
ulcers  often  occur  as  the  result  of  delivery,  as  in  the  case  of  a  tear  fail- 
ing to  heal ;  or  as  the  result  of  distension  of  the  parts  in  the  course  of 
examination,  especially  where  a  speculum  has  been  used.  Syphilitic 
ulcers  are  commonly  found  about  the  orifice.  As  the  result  of  acute 
syphilitic  diseases  in  children,  severe  ulceration,  and  even  sloughing 
and  gangrene  of  the  parts,  is  apt  to  occur. 

An  abscess  about  the  vulva  raises  suspicions  of  gonorrhoea.  Abscess 
of  Bartholini's  gland,  indeed,  is  often  the  result  of  gonorrhoeal  infection 
spreading  up  the  duct  of  the  gland  and  involving  the  gland  itself: 
abscesses,  however,  about  the  vulva  are  not  necessarily  gonorrhoeal. 

The  form  of  cyst  usually  found  at  the  vulva  is  produced  by  a 
blocking  of  the  duct  of  Bartholini's  gland  and  retention  of  the  fluid. 
When  the  cyst  has  persisted  for  some  time  the  walls  become  consider- 
ably thickened,  and  the  only  satisfactory  way  of  dealing  with  it  is  to 
dissect  it  out. 

The  discharge  about  the  vulva  may  be  of  a  simple  or  specific  char- 
acter, and  is  apt  to  occur  in  association  with  fibroids  and  polypi,  can- 
cerous disease  of  the  uterus  (cervix  or  body),  erosion  of  the  cervix,  in 
diseases  of  the  lining  membrane  of  cervix,  body,  and  Fallopian  tubes, 
as  well  as  in  cases  of  general  weakness  and  gonorrhoea. 

Cancer,  beginning  primarily  at  the  vulva,  though  by  no  means  un- 
known, is  exceedingly  rare. 

The  posterior  part  of  the  vulva  and  the  perineum  should  next  be 
examined,  and  a  note  made  whether  the  fourchette  has  been  torn. 

The  hymfrn  in  the  virgin  is  various  in  form.  Usually  it  is  a  crescontic 
fold  of  greater  or  less  depth,  complete  at  its  circumference  and  having  a 
free,  complete  edge.  When  connection  takes  place  it  usually  ha]ipens  that 
one  or  more  splits  occur  in  the  free  margin,  but  no  part  of  the  circumfer- 
ence is  lost.  As  the  result  of  delivery,  if  at  term  almost  invariably, 
and  often  even  when  the  patient  has  not  reached  the  full  time  of 
pregnancy,  y)arts  of  the  hymen  become  lost;  it  is  then  represented  by 
little  pieces  left  at  the  cinnimference  with  vacancies  between  them,  and 


DIAGNOSIS  IN   GYNECOLOGY 


179 


of  course  the  whole  vulva  becomes  at  the  same  time  more  distended  than 
it  was  before.  Parts  of  the  hymen  may  also  be  lost  on  account  of  in- 
tlammatory  disease  and  ulceration  and  sluuyhing,  syphilitic  or  otherwise. 
The  hymen  may  be  thick  and  fleshy,  instead  of  thin  and  membranous  • 
and  such  a  hymen  is  very  likely  to  resist  laceration  during  connection, 
and  occasionally  even  during  delivery ;  especially  if  the  child  be  small 
and  the  patient  have  not  reached  the  full  time  of  gestation.  In  another 
form  of  virginal  hymen  occasionally  met  with  the  vulva  is  closed  by  the 
membrane,  which  has,  however,  small  holes  here  and  there  in  it  —  the 
cribriform  hymen,  as  it  is  called.  In  other  cases  the  hymen  is  exceed- 
ingly tough  and  elastic,  and  the  membrane  is  larger  than  usual,  leaving 
only  a  small  orifice  in  front.  In  such  cases  also  the  membrane  may  es- 
cape laceration,  but,  being  distensible,  it  becomes  considerably  stretched 
by  efforts  at  connection.  Finally,  the  hymen  may  be  imperforate  ;  if  so, 
when  puberty  is  reached  retention  of  the  menses  occurs,  and  the  flow, 
distending  the  vagina  and  uterine  cavity,  causes  the  membrane  to  bulge 
outwards. 

In  examining  the  vagina,  the  size  of  it,  the  character  of  the  mucous 
membrane,  the  presence  of  discharge,  tendency  to  prolapse,  pessaries 
or  foreign  bodies  contained  within  it,  and  cj'sts  or  growths  in  its  wall 
are  to  be  ascertained. 

The  vagina  in  the  virgin  is  much  shorter  than  in  persons  who  have 
had  connection,  though  it  varies  much  in  individual  subjects:  it  is  still 
more  enlarged  by  the  process  of  parturition.  The  tone  of  the  vagina 
should  be  noted ;  for  when  the  tissues  are  lax  and  wanting  in  tone  the 
vagina  may  be  exceedingly  large.  Perhaps  the  largest  vaginas  we  meet 
with  occur  in  hysterical  women,  in  whom  what  is  known  as  "  ballooning  " 
of  the  vagina  occurs ;  so  far  as  I  am  aware  no  very  satisfactory  expla^ 
nation  of  this  condition  has  yet  been  given.  The  vagina  may  also  be 
capacious  in  persons  who  have  worn  pessaries  for  uterine  displacements 
or  other  conditions. 

The  colour  of  the  mucous  membrane  of  the  vagina,  as  of  the  vulva, 
indicates  the  existence  of  gestation,  the  presence  of  some  tumour,  or  a 
congested  condition  produced  by  more  or  less  general  disease  or  local 
inflammation.  On  examination,  especially  with  the  speculum,  one  may 
come  across  spots  either  redder  or  paler  than  the  general  surface  of  the 
mucous  membrane :  the  exact  significance  of  these  spots,  I  believe,  is 
as  yet  unknown. 

Ulcers  may  also  be  found  in  the  vagina,  either  of  a  simple  or 
syphilitic  character. 

Finally,  some  discharge  may  be  present,  and  its  quantity,  colour,  and 
consistence  should  be  observed.  It  may  be  watery ;  or  thick  and  yel- 
low; or  thick  and  clear  like  unboiled  white  of  Qg^;  almost  jelly-like 
in  consistence  ;  or  milky  and  opaque. 

The  walls  of  the  vagina  are  prone  to  eversion  and  prolapse.  Pro- 
lapse of  the  anterior  wall  with  the  bladder  (cystocele)  is  the  more  com- 
mon.    If  this  condition  be  not  well  marked  it  may  pass  unrecognized. 


■:8o  SyS7'£M   OF  GYN.-ECOLOGY 

unless  the  patient  be  directed  to  hold  her  breath  and  strain  down,  or 
she  be  examined  in  the  standing  posture. 

Rectocele- —  a  prolapse  of  the  posterior  vaginal  wall  involving  the 
rectiun  —  is  less  common,  though  frequently  the  two  occur  together.  On 
further  straining  the  cervix  will  often  come  down  and  pass  the  vulva ;  and 
in  the  worst  cases  even  the  fundus  will  lind  its  way  outside,  the  vaginal 
walls  being  completely  everted,  complete  prolapse  of  the  bladder,  uterus, 
and  frequently  of  the  rectum  as  well,  taking  place.  The  presence  of  the 
bladder  outside  may  be  demonstrated  by  passing  a  sound  into  the  bladder 
and  observing  the  position  of  the  point  in  the  prolapsed  inass.  Rectocele 
may  be  recognised  by  passing  the  finger  into  the  bowel. 

The  x^resence  of  pessaries  or  foreign  bodies  in  the  vagina  will  not 
escape  notice.  Pessaries  are  sometimes  put  into  the  vagina  without 
the  knowledge  of  the  patient ;  or  may  sometimes  be  forgotten  and  left 
there  for  a  considerable  time.  Their  presence  is  apt  sooner  or  later 
to  set  up  vaginitis,  unless  the  patient  takes  means  to  ensure  cleanliness 
by  the  use  of  vaginal  douches. 

Cysts,  by  no  means  common,  are  occasionally  found  even  at  the  upper 
part  of  the  passage.  A  case  sent  to  me  as  one  of  small  ovarian  tumour 
proved  to  be  a  cyst  at  the  roof  of  the  vagina.  The  wall  of  the  vagina  is 
frequently  infiltrated  by  malignant  disease  extending  from  the  cervix. 

T}ie  cervix  may  be  outside  the  vagina,  or  high  up,  even  out  of  reach, 
especially  when  the  bladder  is  full ;  it  may  be  just  within  the  vulva ;  it 
may  be  far  forwards;  it  may  be  backwards  on  the  perineum,  or  back- 
wards and  high  up  ;  or  it  may  be  to  one  side  or  other  of  the  middle  line. 
Its  shape  is  to  be  noted.  The  length  of  the  vaginal  part  of  the  cervix  — 
the  part,  that  is,  which  projects  into  the  vagina  —  must  be  observed ;  its 
consistence  also ;  its  mobility,  whether  it  appears  to  be  free  or  attached 
and  limited  in  its  movements ;  the  condition  and  colour  of  the  mucous 
membrane  will  be  seen  by  using  a  speculum  (generally,  for  purposes  of 
diagnosis,  a  Fergusson's  speculum)  ;  as  also  any  erosion  on  one  or  other 
lips  of  the  cervix,  or  ulceration  ;  and,  finally,  the  secretion  passing  from 
the  cervix. 

In  speaking  of  the  conditions  which  cause  the  position  of  the  cervix 
to  vary  I  must  anticipate  a  little,  for  the  position  of  the  cervix  has  often 
to  be  considered  in  relation  to  the  position  of  the  fundus.  The  cervix  is 
lower  than  it  should  be  in  cases  of  prolapsed  and  of  procident  uterus,  and 
in  supravaginal  and  inf  ravaginal  elongation ;  but  when  the  uterus  is 
merely  prolapsed  or  procident  the  fundus  falls  with  it,  and  their  relative 
position  is  preserved.  In  cases  of  infravaginal  elongation,  in  which  the 
cervix  is  usually  lengthened  out  into  a  cone  surmounted  by  a  small  orifice, 
the  fundus  maintains  its  proper  position ;  but  the  cervix  itself  is  elongated 
and  the  canal  lengthened.  This  is  a  congenital  affection  usually  associated 
with  dysmenorrhfjia  and,  if  the  patient  be  married,  with  sterility  also. 
In  cases  of  supravaginal  elongation  the  intravaginal  cervix  is  not  elon- 
gated; but  the  cervix  falls  while  the  fundus  relatively  nuuntains  its 
normal  position,  though  it  is  often  associated  with  some  descent  of  the 


DIAGNOSIS  IN   GYNyECOLOGY  l8l 

uterus  as  a  whole :  extension  takes  place  between  the  attachment  of  the 
uterus  to  the  parts  around  and  the  roof  of  the  vagina.  In  this  case  also 
the  canal  is  lengthened  In  anteflexion  the  cervix  usually  maintains  its 
position  so  long  as  the  anteflexion  is  anteflexion  pure  and  simple ;  but 
where  version  takes  place  the  cervix  is  found  higher  up  and  farther  back 
than  usual.  In  retroflexion  pure  and  simple  the  cervix  maintains  its 
position  though  the  body  fall ;  but  when  retroversion  takes  place  the 
cervix  approaches  the  symphysis  while  the  body  tilts  backwards. 
Anteflexion  is  not  infrequently  found  in  association  with  retroversion, 
in  which  case  the  body  falls  in  the  pelvis,  and  at  the  same  time  the 
cervix  approaches  the  symphysis  and  its  orifice  becomes  directed 
forwards,  often  looking  towards  the  top  of  the  symphysis  instead  of 
downwards  and  backwards.  Irregularity  of  the  cervix  may  be  the 
result  of  laceration  occurring  during  delivery  or  in  the  course  of  an 
operation.  Lacerations  occurring  during  parturition  are  more  frequently 
found  on  the  left  than  on  the  right  side,  and  if  both  sides  are  involved 
the  left  is  usually  more  so  than  the  right.  Where,  too,  bilateral  lacer- 
ation has  occurred,  the  lips  of  the  cervix  may  become  averted  so  that 
they  actually  fall  into  the  same  plane.  All  cases  of  flexion  and 
version  are  apt  to  be  accompanied  by  some  descent  of  the  uterus  as 
a  whole.  Carcinoma  produces  more  or  less  irregular  nodulation  either 
in  the  substance  of  the  cervix  or  on  its  surface,  which  imparts  to  the 
examining  finger  a  gristly  feel.  A  cauliflower  excrescence  springing 
from  the  cervix  may  be  at  once  put  down  to  malignant  disease.  In 
consistence  the  cervix  may  be  rendered  much  harder  than  usual  by 
chronic  inflammation  set  up  in  consequence  of  lacerations  and  tears,  such 
as  occur  after  repeated  deliveries,  especially  where  instruments  have 
been  used.  Primary  syphilitic  sores  are  rarely  found  on  the  cervix,  but 
when  present  preserve  their  usual  hard  character.  The  cervix  is  rendered 
hard  also  by  malignant  disease  which,  after  a  time,  breaks  down  towards 
the  centre,  still  leaving  a  hardened  infiltrated  margin.  In  consistence  it 
is  diminished  in  pregnane}^,  in  subinvolution,  and  in  many  cases  of 
inflammation  of  the  lining  membrane,  especially  when  associated  with 
hiemorrhage  and  copious  discharge.  The  mobility  of  the  cervix  may  be 
diminished  either  from  the  presence  of  some  extraneous  tumour  pressing 
the  uterus  downwards  or  to  one  side  ;  or  as  the  result  of  some  inflamma- 
tory condition  with  effusion,  adhesion,  or  cicatricial  contraction  resulting 
therefrom  ;  or,  finall_y,  as  the  result  of  cancerous  groAvth  in  its  substance 
which  has  spread  and  involved  the  cellular  tissue  outside.  Tlie  mobility 
is  abnormally  increased  when  the  parts  are  lax  and  the  ligaments  have 
become  stretched,  as  occurs  in  cases  of  prolapse,  procidentia,  etc. 

The  colour  of  the  mucous  membrane  will  indicate  congestion  or 
inflammation.  In  cases  of  metritis  it  becomes  of  a  florid  red  colour;  its 
colour  is  dull  or  bluish  when  the  blood-supply  is  partially  arrested,  either 
from  incomph^c  strangulation,  as  in  prolapse;  or  from  the  pressure  of 
tumours  in  the  pelvis  or  abdomen;  or  as  the  result  of  intiammatory 
effusions,  or  of  obstruction  to  the  circulation  in  disease  of  the  heart  and 


i82  SYSTEM   OF  GYNAECOLOGY 

liver.  In  prolapse  of  the  vaginal  walls  the  nineous  membrane  after  a 
time  becomes  thickened  and  the  surface  dry. 

Erosions  Vary  much  in  appearance.  Sometimes  they  are  florid ; 
sometimes  they  are  oedematous  and  readily  bleed  when  touched.  When 
healing  they  take  on  a  bluish  line  at  the  margin :  the  part  which  has 
healed  over,  which  has  become  cicatrised,  that  is,  with  a  stratitied  layer 
of  epithelium,  is  of  a  whity-bluish  coloiir,  different  from  the  rest  of  the 
cervix.  Proliferation  of  the  gland  structures  often  takes  place;  the 
follicles  become  distended  with  mucus,  and,  the  ducts  being  plugged, 
the  follicles  stand  out  as  glistening  points  dotted  over  the  surface  of 
the  erosion. 

Simple  ulceration  is  uncommon,  except  as  the  result  of  laceration 
or  of  caustic  applications.  Syphilitic  ulceration  —  a  hard  sore  of  the 
cervix  —  is  occasionally  met  with  and  has  the  same  characters  as  hard 
chancres  elsewhere. 

The  secretion  from  the  cervix  is  naturally  a  thick  glairy  mucus,  but 
in  cases  of  severe  inflammatory  mischief  it  often  becomes  purulent. 

The  presence  of  mucous  polypi  in  the  cervix  itself,  growing  from  the 
lax  mucous  membrane,  is  usually  associated  with  a  very  considerable 
amount  of  secretion  from  the  canal  and  often  with  haemorrhage. 

The  body  of  the  uterus  may  present  changes  in  size,  shape,  consistence, 
or  mobility ;  and  it  may  be  tender  to  the  touch. 

The  displacements  of  the  body  which  may  be  met  with  are  prolapse 
—  that  is  to  say,  a  falling  downwards,  which,  when  existing  to  a  marked 
extent,  is  known  as  procidentia ;  anteflexion  ;  retroflexion ;  anteversion 
and  retroversion;  and  a  combination  of  anteflexion  and  retroversion. 
Lateral  displacements  may  sometimes  be  observed,  especially  where  a 
growth  or  swelling  in  the  broad  ligament  displaces  the  uterus  to  the 
opposite  side,  or  adhesions  draw  it  to  the  same  side.  But  lateral 
displacement  may  be  congenital  from  a  shortening  of  the  ligaments  on 
the  side  to  which  it  is  inclined.  Extraneous  tumours  may  displace  the 
uterus  downwards — as  does  ovarian  disease,  which  frequently  at  the 
same  time  produces  retroversion ;  upwards  —  as  does  especially  a  full 
bladder;  forwards  —  as  by  any  swelling  in  the  jDouch  of  Douglas,  such  as 
htematocele,  or  a  mass  of  faeces  in  the  rectum ;  backwards  —  as  again  by 
a  full  bladder  or  ovarian  cyst ;  and  laterally  —  as  by  any  swelling  in  the 
broad  ligament  itself,  such  as  an  extra-uterine  gestation,  a  parovarian 
swelling,  or  sometimes  a  small  ovarian  tumour. 

The  uterus  may  be  found  of  less  than  normal  diuiensions;  either  as 
a  congenital  defect,  in  which  case  the  ovaries  may  also  be  absent  or 
imperfectly  developed;  after  delivery  as  the  result  of  what  is  known  as 
superinvolution ;  or  at  the  menopause,  as  the  result  of  natural  atrophy. 

The  uterus  frequently  increases  in  size.  Eor  purposes  of  diagnosis 
it  is  well  to  divide  these  enlargements  into  those  which  are  regular  in 
character,  and  those  which  are  ui  an  irregular  form.  IJnifoi'm  or  regular 
(;rdargement  occurs  in  gestation  ;  and,  of  course,  such  cnlargcanent  is  also 
met  with  after  dclivoiy,  in  the  lying  in  period,  l)cforc  the  uterus  has 


DIAGNOSIS  IN   GYNAECOLOGY  183 

returned,  to  its  normal  dimensions,  and.  in  cases  of  subinvolution.  In 
cases  of  inflammation  (metritis  and.  endometritis)  the  uterus  is  in- 
creased in  size ;  the  sound  usually  passes  half  an  inch  to  an  inch  more 
than  the  natural  distance.  In  cases  of  mole  pregnancy  a  regular  en- 
largement of  the  uterus  occurs;  though  occasionally  an  irregular  bulg- 
ing may  be  found  —  especially  in  blood  mole  —  over  the  site  of  the 
effused  blood.  Again,  more  or  less  regular  enlargement  of  the  uterus 
takes  place  in  cases  of  pyometra  and  hamatometra ;  cases,  that  is  to 
say,  of  pus  and  blood  inside  the  uterine  cavity.  Pyometra  is  usually 
met  with  in  old  women,  but  is  not  a  common  condition ;  htematometra, 
as  a  rule,  belongs  to  cases  of  imperforate  hymen. 

Among  irregular  enlargements  of  the  uterus,  myomas  or  fibroid 
growths  are  the  most  common.  Cancer  of  the  uterus  also  produces 
more  or  less  irregular  enlargement  of  the  body ;  though  it  may  appear 
uniform,  as  it  may  also  in  enlargement  due  to  fibroid.  Cancer  of  the 
body,  in  comparison  with  carcinoma  of  the  cervix,  is  a  rare  disease, 
occurring  late  in  life.  Sarcoma  of  the  body,  another  rare  condition, 
also  produces  more  or  less  irregular  enlargement. 

As  regards  consistence,  we  may  take  it  as  a  general  rule  that  soft 
enlargements  of  the  body  of  the  uterus  are  usually  the  result  of  ges- 
tation, when,  be  it  noted,  there  is  a  hard  body  inside  the  fluid  one. 
In  hydatidiform  mole  enlargement  takes  place  rapidly  and  is  of  a 
soft  character.  In  subinvolution  the  consistence  is  diminished ;  and 
the  same  description  usually  applies  to  metritis  unless  it  has  become 
chronic;  and  also  to  pyometra  and  hsematometra,  unless  the  distension 
be  very  great,  in  which  case  the  enlarged  organ  is  hard.  In  rapidly 
growing  fibroids  and  fibro-cystic  swellings  the  enlargement  is  usually 
soft  and  semi-fluctuating,  and  a  uterine  bruit  may  often  be  heard. 

The  enlargements,  in  which  the  consistence  is  increased,  are  usually 
the  result  of  fibroid  masses,  unless  rapid  growth  be  taking  place  or 
oedema  be  also  present,  as  for  instance  when  the  enlarged  uterus  be- 
comes impacted  in  the  pelvis.  Cancerous  enlargements  are  usually  hard ; 
so  also  are  sarcomatous  tumours.  Blood  and  fleshy  moles  (in  contradis- 
tinction to  hydatidiform  moles)  cause  abnormal  hardness  of  the  uterus. 

In  considering  the  mobility  of  the  uterus,  it  has  to  be  remembered 
that  it  is  usually  increased,  as  the  result  of  laxity  of  the  tissues,  by 
frequent  child-bearing  or  by  operations  in  which  the  uterus  has  been 
dragged  upon.  It  is  decreased  as  the  result  of  extraneous  tumours  pre- 
venting free  movement,  Avhether  these  tumours  be  above,  below,  to  one 
side,  or  at  the  back  of  the  uterus.  In  cases  of  inflannnatory  mischief 
the  uterus  may  be  either  pushed  to  one  side  by  the  effused  products,  or 
drawn  by  adhesions  to  surrounding  structures ;  or,  if  the  effusion  have 
occurred  in  the  cellular  tissue ;  it  may  be  drawn  and  fixed  by  the  con- 
traction which  subsecjuently  occurred.  In  any  case  the  movements  of 
the  uterus  are  restricted.  The  mobility  is  decreased  also  by  new 
growths  spreading  and  involving  the  tissues  beyond  the  uterus,  as  in 
cancer  and  sarcoma ;  or  when  from  any  cause  the  uterus  falls  into  the 


iS4  SYSTEM   OF  GYN.-^COLOGY 

pelvis  and  becomes  impacted.  In  severe  cases  of  retroflexion  and  of 
retroversion  the  fundus  may  be  grasped  and  held  down  in  the  floor  of 
the  pouch  of  Douglas  by  the  sacro-uterine  ligaments. 

The  uterus  becomes  tender  to  the  touch  from  congestion,  from  in- 
flammation of  the  tissue  of  the  uterus  itself,  or  from  such  inflammatory 
mischief,  in  the  immediate  neighbourhood,  as  occurs  in  ovaritis,  pro- 
lapsed ovaries  with  congestion,  pelvic  peritonitis,  and,  lastly,  as  the 
result  of  adhesions  to  surrovmding  structures. 

Tumours  in  the  Pelvis.  —  In  investigating  pelvic  tumours  the  points 
to  be  noted  are  their  position ;  their  size ;  their  shape ;  their  consist- 
ence ;  their  mobility ;  the  presence  of  tenderness  on  manipulation ;  and 
their  apparent  attachment,  which  is  estimated  by  endeavouring  to  move 
the  tumour,  and  ascertaining  upon  what  parts  it  appears  to  drag,  and 
upon  what  parts  the  movement  of  the  tumour  has  no  effect. 

The  tumours  in  the  pelvis  may  be  divided,  according  to  the  part 
from  which  they  originate;  into  eight  heads,  as  follows.  (In  this  cate- 
gory tumours  of  the  vagina  and  vulva  are  not  included  because  those 
affecting  the  lower  part  of  the  canal  have  been  already  mentioned.) 

i.  Tumovirs  of  the  Uterus  itself  are  —  Inversion,  either  partial  or 
complete.  Fibroid  polypi,  which  may  be  either  in  the  vagina,  lying  in 
the  cervix  of  the  uterus  and  distending  it,  or  still  remaining  in  the 
cavity  of  the  uterus :  myoma  of  the  cervix  very  frequently  grows  down 
into  the  vagina,  occasionally  into  the  broad  ligament :  myoma  of  the 
body  of  the  uterus  begins  in  various  parts  and  grows  in  various  direc- 
tions as  submucous,  interstitial  or  subperitoneal.  Fibroids  are  frequently 
multiple,  and  interstitial  growths  are  frequently  found  in  association 
with  a  polypus  or  a  subperitoneal  fibroid;  as  they  grow,  they  may  ex- 
tend into  the  broad  ligament,  especially  when  they  begin  low  down  or 
on  one  side  of  the  uterus,  and  subperitoneal  fibroids  are  apt  to  fall  into 
the  pouch  of  Douglas  and  become  impacted  there.  Cancer  of  the  cervix, 
subsec^uently  extending  to  the  body  as  well  as  to  the  vagina :  primary 
cancer  of  the  body.  Sarcoma  of  the  body  of  the  uterus.  The  body  of 
the  uterus  itself,  taking  up  a  faulty  position,  such  as  has  been  already 
mentioned  in  retroflexion  or  version,  may  form  a  tumour.  Retroversion 
of  the  gravid  uterus  impacted  in  the  pelvis  must  also  be  mentioned. 

ii.  Tumours  connected  with  the  Fallopian  Tubes.  —  One  or  both  tubes 
may  be  distended  with  serum,  pus,  or  blood,  giving  rise  to  hydrosalpinx, 
pyosalpinx,  and  haimatosalpinx  respectively ;  the  tubes  themselves  being 
usually  thickened  and  adherent.  Tuljal  gestations  frequently  rupture 
either  into  the  peritoneal  cavity,  giving  rise  to  haematocele,  or  into  the 
Vjroad  ligament  giving  rise  to  haematoma.  Occasionally  part  or  the 
whole  of  the  gestation  sac  may  be  extruded  from  the  fimbriated  extrem- 
ity ftiibal  aVjortion),  or,  less  often,  find  its  way  into  the  uterine  cavity. 

iii.  Tumours  of  the  Ovaries.  — Prolapsed  ccmgested  ovary,  forming  a 
swelling  not  usually  of  lai'gc  size,  is  by  no  means  an  uncommon  condition ; 
and  is  frerpiently  foiuid  associated  with  retivjvei'sion  of  the  uterus  and 
general  laxity  of  the  tissues.     CJystoma  of  the  ovary,  that  is  to  say,  the 


DIAGNOSIS  IN  GYNECOLOGY  185 

ordinary  cystic  ovary ;  dermoid  tumours  of  the  ovary,  and  parovarian 
cyst,  which  is  really  a  tumour  of  the  broad  ligament,  arise  in  the  ova- 
rian region. 

iv.  Tumours  of  the  Cellular  Tissue  are  haematoma,  serous  effusion, 
(parametritis),  and  abscess. 

V.  Tumours  of  the  Pelvic  Peritoneum  are  hsematocele  ;  serous  peri- 
metritis, that  is  to  say,  a  localised  peritonitis  with  effusion ;  and  abscess. 

Adhesion  and  the  matting  together  of  the  intestines,  tubes,  and 
ovaries  in  the  pouch  of  Douglas  frequently  gives  the  impression  of  a 
distinct  tumour  in  that  situation.  A  loop  of  intestine  containing  faeces 
may  easily  be  mistaken  for  some  other  tumour  in  the  pouch  of  Douglas. 

vi.  Tumours  connected  with  the  Rectum  are  fsecal  accumulation ; 
malignant  and  other  growths. 

vii.  Tumours  connected  with  the  Bladder.  —  The  most  common  is 
scarcely  worthy  to  be  called  a  tumour,  though  it  frequently  simulates 
one,  namely,  distension  of  the  bladder  from  the  accumulation  and  reten- 
tion of  urine.  Stone  in  the  bladder  is  a  very  uncommon  condition  in 
women,  but  may  occasionally  be  met  with. 

viii.  Retroperitoneal  Growths  are  such  as  lipoma,  sarcoma,  osteoma 
of  the  bones  of  the  pelvis  ;  a  contracted  pelvis. 

II.  Examination  by  means  of  the  Sound.  —  For  purposes  of  diagnosis 
the  sound  serves  as  a  measure  of  the  length  of  the  uterus,  of  the  size  of 
the  canal,  and  of  its  direction  ;  moreover,  by  careful  use  of  it  other  facts 
may  be  inferred,  such,  for  instance,  as  disease  of  the  mucous  membrane 
from  the  passage  of  blood  or  discharge  after  its  use.  To  some  extent, 
also,  the  condition  of  the  canal  may  be  inferred  by  noting  whether  its 
introduction  or  removal  is  associated  with  pain  as  it  passes  the  inner 
orifice. 

When  the  sound  touches  the  fundus  it  usually  produces  pain  which 
is  generally  referred  to  the  region  of  the  umbilicus. 

In  speaking  of  the  conditions  which  produce  increase  in  length,  it 
must  be  remembered  that  after  child-birth  the  uterus  rarely  returns  to 
the  size  of  the  unimpregnated  organ ;  but  the  difference  is  usually  not 
more  than  a  quarter  of  an  inch.  Elongation  of  the  canal  may  be  due 
to  subinvolution ;  to  chronic  metritis  ;  to  polypi,  submucous  and  inter- 
stitial fibroids;  to  sarcoma  and  carcinomatous  disease  of  the  body;  and 
to  supravaginal  and  infravaginal  elongation  of  the  cervix.  Shortening 
of  the  canal  may  be  due  to  partial  inversion  (in  complete  inversion  it 
is  obliterated) ;  to  superinvolution  ;  to  the  natural  atrophy  which  occurs 
after  the  menopause,  and  to  faulty  development. 

The  canal  may  be  congenitally  narrow,  especially  at  the  inner  orifice ; 
or  contracted  and  even  oliliterated  by  caustic  applications ;  or  as  the 
result  of  operation,  for  example,  supravaginal  amputation.  The  canal 
may  be  dilated  in  various  conditions  during  pregnancy  and  after  deliv- 
ery ;  also  by  the  passage  of  polypi  and  from  loss  of  blood.  Its  direction 
may  be  altered  by  versions  and  flexions,  or  by  the  presence  of  fibroid 
or  other  mass  encroaching  upon  its  lumen. 


i86  SYSTEM   OF  GYNECOLOGY 


IV.  Examination  by  the  Bladder  and  Rectum.  —  In  some  cases  where 
a  tumour  seems  to  be  in  the  pouch  of  Douglas,  but  cannot  be  well  de- 
fined, an  examination  by  the  rectum  may  set  aside  the  possibility  of  its 
rectal  origin ;  and  in  many  cases  examination  by  the  rectum  with  the 
finger  of  one  hand  may  be  combined  with  that  by  the  vagina  with  the 
finger  of  the  other.  Examination  by  the  rectum  is  often  of  considerable 
use  in  determining  the  height  of  the  fundus ;  the  size  of  the  fundus ; 
the  size  of  the  body,  and  the  presence  or  absence  of  the  ovaries  and 
disease  of  the  tubes.  In  some  cases,  to  determine  the  size  of  the  uterus 
or  the  presence  or  absence  of  the  uterus  from  its  normal  position,  it  may 
be  advisable  to  examine  through  the  urethra  either  with  the  sound  or 
with  the  finger ;  for  instance,  in  some  doubtful  cases  of  inversion.  If 
the  finger  be  employed,  it  is  often  better  to  incise  the  vesico-vaginal 
septum,  which  readily  heals,  than  to  dilate  the  urethra  with  the  risk  of 
permanent  incontinence.  Examination  of  the  bladder  may  be  combined 
with  a  digital  examination  by  the  rectum. 

In  all  cases  I  would  recommend  a  bimanual  method  in  making  inter- 
nal examinations ;  it  is  accomplished  with  far  greater  ease  and  ensures 
much  greater  accuracy. 

V.  Additional  Means  of  Examination.  —  In  some  cases,  however,  it 
will  be  found  that  the  means  already  suggested,  even  if  adopted,  are 
not  sufficient  to  clear  up  the  nature  of  the  case.  Especially  is  this  so 
when  the  patient  is  difficult  to  examine,  as  in  cases  of  vaginismus  ;  when 
the  parts  are  contracted ;  when  the  patient  holds  her  breath  and  strains, 
and  particularly  when  it  is  necessary  to  ascertain  the  exact  connections 
of  a  tumour  in  the  pelvis,  and  to  determine  whether  it  be  freely  mov- 
able or  not.  In  such  cases  the  advantage  of  an  anaesthetic  are  very 
great.  In  other  cases,  again,  some  difficulty  arises  in  passing  a  sound, 
which  may  get  fitted  into  little  pouches  in  the  canal.  If  the  passage  of 
the  sound  be  necessary  to  diagnosis,  it  is  well  to  fix  the  cervix  with  a 
volsella.  This  does  not  necessarily  involve  the  use  of  an  anaesthetic  in 
married  women ;  but  it  is  frequently  expedient  that  the  examination 
may  be  complete.  In  the  examination  of  young  unmarried  women  an 
anaesthetic  is  often  desirable  on  other  grounds. 

There  are  other  cases,  again,  when  it  is  necessary  to  dilate  the  cervix 
and  explore  the  uterus.  Dilatation  may  be  effected  under  an  anaesthetic 
with  Hegar's  dilators ;  and  it  is  often  called  for,  not  only  in  deciding  the 
cause  of  haimorrhage  from  the  uterus,  but  also  as  a  ]')reparatory  step  in 
operations  for  its  relief.  When  the  cervix  is  unusually  rigid  laminaria 
tents  may  also  be  used  with  advantage. 

Finally,  it  may  be  necessary,  before  arriving  at  a  diagnosis,  to  remove 
portions  of  tissue  for  microscopic  examination  ;  as  in  the  case  of  erosions  of 
the  cervix  of  doubtful  malignancy,  and  in  cases  of  hannorrhage  from  the 
uterus  with  irregularities  of  the  surface,  wliich  may  be  of  a  malignant 
nature;  or,  again,  to  determine  whether  retained  products  are  the  result 
of  gestation  or  of  some  inflammatory  condition  of  tlie  mucous  membrane. 

It  is  not  always  possible  to  arrive  at  a  correct  diagnosis  on  first 


INFLAMMATION  OF  THE    UTERUS  187 

seeing  the  patient ;  time  is  often  an  important  factor  in  forming  a  correct 
opinion.  But  while  tlie  precise  nature  of  tlie  case  remains  undetermined 
the  patient  may  often  with  manifest  advantage  be  placed  under  provi- 
sional treatment  to  give  relief  to  her  instant  sufferings,  and  to  assist  the 
physician  in  arriving  at  a  complete  diagnosis  of  the  case.  Take,  for 
instance,  the  case  of  a  swelling  in  the  pelvis,  the  nature  of  which  is  at 
first  undeterminable.  The  symptoms  and  physical  signs  point  to  inflam- 
matory mischief;  and  for  a  time  it  may  not  be  possible  to  distinguish,  and 
to  exclude  some  cystic  or  other  swelling  at  the  bottom  of  it,  such  as  a  rupt- 
ured ectopic  gestation.  The  patient  is  put  to  bed  and  kept  quiet;  hot 
douches  are  ordered  to  allay  inflammation ;  and  the  bowels  are  regulated 
with  a  view  to  avoid  irritation  of  the  inflamed  parts  in  the  pelvis.  If, 
after  a  time,  the  temperature,  which  perhaps  was  considerably  raised,  has 
under  this  treatment  fallen  to  normal ;  if  the  tenderness  and  pain  have 
gradually  subsided  or  disappeared ;  if  the  swelling  has  diminished  in  size, 
and  the  parts  which  were  previously  fixed  have  become  mobile,  it  may 
be  reasonably  concluded  that  the  swelling  probably  consisted  entirely  of 
inflammatory  effusion.  But  such  cases  do  not  always  end  thus.  For 
example,  after  the  temperature  has  been  normal  for  a  week,  and  the 
patient  has  then  risen  from  bed,  the  inflammatory  mischief  may  reassert 
itself.  We  are  thus  led  to  think  that  something  more  than  the  mere 
inflammatory  mischief  remains  behind;  and  after  a  time  some  definite 
swelling  may  be  recognised.  In  cases  such  as  these  a  correct  diagnosis 
can  only  be  reached  by  care  and  vigilance.  It  is  important  also  to  have 
the  opportunity  of  noting  any  changes  in  the  symptoms  and  physical 
signs  while  the  patient  is  under  treatment,  and  to  be  prepared  to  modify 
the  diagnosis  according  to  the  results. 

Robert   Boxall. 

REFERENCES 

1.  CoHNSTEiN,  J.  "Die  gynukoloffisclie  Diagnostik,"  VolJcmann's  Sammlunff,  "No. 
89.  Leipzig,  1875. — 2.  Keating,  John  M.  and  Henry  C.  Coe.  Clinical  Gj/nxfologj/, 
Medical  and  Surgical,  hy  American  Teachcrx,  2  vols.  Edin.  and  Lond.  18!)5.  — .'?.  Mann, 
Matthew  D.  A  System  of  Gynecology  by  American  Authors,  2  vols.  Edin.  1887, 
1888. — 4.  Pean,  J.  Diagnostic  et  traitement  des  tumeurs  de  I'abdomen  et  du  bassin,  2 
vols.  Paris,  1880,  1885.  — 0.  Veit,  Johann.  Gynlikologische  Diagnostik.  Stuttgart, 
1891.  —  6.  Wells,  T.  Spencer.  Diagnosis  and  Surgical  Treatment  of  Abdoniinal 
Tumours.    Loud.  1885. 

R.  B. 


INFLAMMATION   OF   THE   UTERUS 

Few  subjects  in  gynaecology  are  so  difficult  to  handle  as  inflammation 
of  the  uterus.  Seldom  fatal,  and  therefore  not  lending  itself  to  the  pre- 
cise methods  of  the  pathologist,  its  pathological  anatomy  is  being  but 
slowly  worked  out.     Clinically  it  includes  a  long  series  of  cases  showing 


SYSTEM   OF  GYNECOLOGY 


the  most  varied  changes.  Beginning  with  those  in  which  the  only 
symptom  is  pain,  and  the  only  physical  sign  undue  sensitiveness  on 
examination,  —  cases  which  led  that  careful  clinician  Gooch  to  describe 
what  he  called  the  "  irritable  uterus,"  —  it  further  signifies  groups  of 
cases  which  show  all  the  marks  of  local  inflammation,  but  usually  present 
no  distinct  line  of  demarcation  between  the  acute  and  the  chronic.  Be- 
sides being  rarely  fatal,  except  in  cases  of  puerperal  sepsis,  which  belong 
rather  to  the  domain  of  obstetrics  than  of  gynaecology,  another  peculi- 
arity of  inflammation  of  the  uterus  is  the  rarity  of  suppuration  which  is 
so  common  a  result  of  inflammation  in  other  organs.  We  are  not  sur- 
prised, therefore,  to  find  a  great  divergence  of  opinion  among  leading 
gynseeologists  in  Britain  and  elscAvhere  on  the  nature  and  relative  im- 
portance of  the  various  forms  of  uterine  inflammation. 

A  retrospect  of  the  opinions  held  during  the  last  half  century  on  the 
significance  of  the  various  inflammatory  lesions  in  the  pelvis  brings  out 
two  curious  facts.  The  first  is  the  influence  of  methods  of  examination 
in  accentuating  a  lesion.  The  speculum  concentrated  attention  on  the 
cervix,  the  sound  on  the  position  of  the  uterus  ;  the  bimanual  examina- 
tion on  the  cellular  tissue  and  peritoneum ;  the  exploratory  incision  on 
the  uterine  appendages,  and  the  microscope  on  micro-organisms.  On  the 
introduction  of  each  of  these  methods  of  examination  the  corresponding 
lesion  has  been  emphasised  out  of  all  proportion  to  the  rest.  An  expert 
in  any  one  method  of  examination  is  disposed  to  say — This  is  the  lesion, 
and  there  is  no  other.  At  present  abdominal  section  and  the  microscope 
hold  the  field  ;  and  a  historical  survey  warns  us  that  at  the  present  time 
we  are  exposed  to  the  danger  of  emphasising  the  significance  of  inflam- 
matory lesions  of  the  uterine  appendages,  and  even  of  the  part  played 
Ijy  micro-organisms,  at  the  expense  of  other  lesions  and  other  factors  of 
no  less  importance. 

Another  striking  feature  in  such  a  retrospect  is  the  progress  in  the 
mode  of  regarding  disease.  Half  a  century  ago  the  standpoint  was  a 
symptomatic  one.  Tyler  Smith's  book  on  Leucori'hoea,  in  which  the  most 
varied  conditions  are  grouped  together  because  they  have  this  symptom 
in  common,  is  an  illustration  of  the  symptomatic  standpoint.  At  the 
present  day  the  standpoint  is  pathological;  the  "entity  leucorrhoea" 
has  been  replaced  by  ''endometritis"  and  "cervical  catarrh,"  under 
which  names  the  lesion  is  localised  and  described.  But  the  changed 
standpoint  does  not  simply  mean  seeing  another  side  of  the  same  thing. 
We  are  not  merely  walking  round  a  hill,  we  are  ascending  it ;  the 
pathological  standpoint  is  a  step  higher  than  the  symptomatic :  a  step 
higher  still  will  bring  us  to  an  etiological  standpoint,  inasmuch  as 
etiology  deals  with  causation,  and  is  the  basis  of  pi-eventive  medicine. 
Wlif-re  it  has  been  demonstrated,  as  in  the  case  of  gonorrhoea,  that  the 
inflammatory  conditions  of  the  uterus  are  due  to  a  micro-organism,  this 
view  of  inflammation  from  the  etiological  standpoint  has  simplified  our 
conception  of  it.  Instead  of  Vjeing  broken  up  artificially  into  different, 
affections  according  to  the  tissues  involved  for  the  time  being,  it  has 


INFLAMMATION  OF  THE    UTERUS  189 

become  an  organic  unity,  gathered  round  the  life-history  of  a  micro- 
organism. Clinical  experience  tells  us  that  this  is  the  true  mode  of 
regarding  it. 

And  yet,  if  it  should  be  shown  that  all  the  changes  which  we  associate 
with  metritis  have  a  microbe  at  the  bottom  of  them  as  the  essential  factor 
in  their  production,  this  would  not  produce  a  great  revolution  in  our  con- 
ception of  metritis,  although  it  would  materially  influence  our  treatment 
in  so  far  as  it  might  emphasise  preventive  treatment  by  antiseptics. 
After  all  the  micro-organisms  have  been  discovered  and  described,  atten- 
tion will  again  revert  to  the  local  and  general  conditions  which  determine 
their  growth.  If  the  microbe  or  spore  be  the  seed  the  uterus  is  the 
soil,  and  those  subtle  influences  which  we  speak  of  as  constitution  and 
diathesis  are  the  climate.  The  seed  is  an  essential  factor  in  plant  life, 
but  equally  important  factors  for  development  and  growth  are  soil  and 
climatic  conditions.  The  discovery  of  the  seeds  has  for  the  time  thrown 
the  study  of  constitutional  states  and  diatheses  into  the  background. 
But  because  we  know  little  about  them  we  need  not  minimise  their 
influence.  No  science  is  so  vague  as  meteorology,  and  yet  nothing 
bulks  so  largely  in  the  farmer's  mind  as  the  weather.  Of  the  importance 
of  soil  no  better  illustration  could  be  found  than  in  the  case  of  the  puer- 
peral uterus.  If  Winter's  observations  are  correct,  the  staphylococcus 
pyogenes  albus,  aureus,  and  citreus,  as  well  as  various  forms  of  strepto- 
cocci, are  present  beforehand  in  the  uterus,  but  lie  harmless  until  the 
puerperal  state  supplies  the  conditions  favourable  for  their  development. 

To  Henry  Bennet  is  due  the  credit  of  drawing  attention  to  the 
importance  of  inflammation  of  the  uterine  mucous  membrane  (2). 
Although  he  described  it  as  in  many  cases  going  on  to  ulceration,  so 
that  his  opponents  fastened  on  the  alleged  "  ulceration,"  and  criticised 
it  as  the  essence  of  Bennet's  teaching,  it  is  only  fair  to  him  to  say  that 
he  regarded  ulceration  as  but  one  of  many  phases  of  inflammation. 
Perhaps  he  laid  himself  open  to  criticism  b}^  stating  that  inflammation 
was  to  be  treated  by  surgical  means. 

Bennet's  views  were  opposed  by  Lee  and  West  (40)  and  Tyler  Smith. 
In  reaping  their  criticisms  it  is  interesting  to  come  upon  statements,  then 
based  only  on  clinical  observation,  which  have  since  been  established  by 
microscopic  investigation.  Thus  Lee,  speaking  of  the  appearances  which 
Bennet  described  as  ulceration,  says  :  "  These  apparent  granulations  are 
usually  considered  and  treated  as  ulcers  of  the  os  and  cervix  uteri,  but 
they  do  not  present  the  appearances  which  ulcers  present  on  the  surface 
of  the  body,  or  in  the  mucous  membranes  lining  the  viscera,  and  they 
are  not  identical  with  the  granulations  which  fill  up  healthy  ulcers.  They 
present  the  appearances  often  observed  on  the  tonsils  which  are  said  U) 
be  ulcers,  and  are  not "  (21).  Thus  Lee,  writing  in  1850,  forecasts  the 
work  of  Euge  and  Yeit  in  1878.  The  comparison  of  the  "  ulcerated  " 
cervix  to  a  hypertrophied  tonsil  is  a  happy  one.  So  also  Tyler  Smith 
forestalled  the  view  of  Emmet  and  Roser,  that  the  appearance  is  pro- 
duced by  an  ectropion  of  inflamed  cervical  mucous  membrane,  when  he 


I90  SYSTEM  OF  GYNAECOLOGY 

says  :  "  The  granulatious  which  are  sometimes  found  surrounding  the  os 
uteri  —  which  may  secrete  mucus  or  pus  abundantly,  and  wliicli  may  bleed 
on  being  roughly  handled — are,  I  have  no  doubt,  the  result  of  inflamma- 
tion ;  but  they  resemble  the  granular  state  of  the  conjunctiva  rather  than 
the  granulations  of  a  true  ulcer,  the  granular  os  uteri  offering  no  edges  or 
signs  of  solution  of  continuity,  by  which  we  might  satisfactorily  declare 
it  to  be  an  ulcer  (37)." 

Unfortunately,  and  in  spite  of  such  criticism,  the  term  ''  ulceration,*' 
introduced  by  Bennet,  took  hold  of  the  professional  mind.  It  led  to  a 
routine  treatment  of  inflammatory  conditions  of  the  cervix  by  caustics, 
as  slowly  healing  ulcers  in  other  situations  are  treated.  An  erroneous 
pathology  opened  the  door  for  a  pernicious  treatment,  from  which  British 
gynaecology  suffered  until  it  found  a  true  pathological  basis. 

Etiology  of  Uterine  Inflammation.  —  While  for  descriptive  purposes 
we  divide  inflammations  of  the  uterus  into  inflammation  of  the  cervix  or 
cervical  catarrh,  of  the  mucous  lining  of  the  body  or  endometritis,  and  of 
the  substance  of  the  uterus  or  metritis,  it  must  be  borne  in  mind  that  no 
one  of  these  occurs  by  itself.  Before  looking  at  these  conditions  sepa- 
rately it  will  be  convenient  to  consider  the  etiology  of  all  three  together, 
inasmuch  as  they  are  produced  by  the  same  causes.  Clinically  the  inflam- 
mation is  not  limited  to  any  one  tissue ;  and  all  that  is  meant  when  a 
case  is  spoken  of  as  endometritis,  is  that  the  changes  in  the  mucous  mem- 
brane in  the  body  of  the  uterus  are  for  the  time  being  more  prominent. 

In  studying  the  etiology  of  inflammation  of  the  mucous  membrane  of 
the  uterus,  we  must  bear  in  mind  that  the  uterine  mucosa  is  not  func- 
tionally analogous  to  other  mucous  membranes,  as  for  example  those  of 
the  stomach,  the  respiratory  tract,  or  bladder.  These  belong  to  organs 
whose  function  is  constant  and  necessary  to  life.  They  are  in  daily  use, 
while  the  function  of  the  uterus,  namely,  reproduction,  is  only  called  into 
exercise  occasionally.  Even  the  periodic  changes  connected  with  men- 
struation can  hardly  be  considered  as  a  function  necessary  to  life,  for 
there  is  no  evidence  to  support  the  old  idea  of  its  being  a  monthly  cleans- 
ing or  katharsis,  which  would  make  the  uterus  practically  an  excretory 
organ.  Menstruation  is  connected  with  the  function  of  reproduction,  and 
its  occurrence  is  not  necessary  to  life.  If  then  the  uterine  mucosa  be  not 
analogous  to  other  mucous  membranes,  we  must  be  cautious  in  transfer- 
ring to  the  etiology  of  its  diseases  notions  gained  from  the  study  of  patho- 
logical processes  in  these  others.  Thus  we  are  prepared  for  the  fact  that 
many  of  the  jn-ocesses  which  we  have  to  describe  under  endometritis 
are  more  allied  to  new  formation  than  to  inflammation,  or  at  any  rate, 
to  the  inflammation  we  are  accustomed  to  study  in  mucous  membranes 
elsewhere.  Were  we  to  subject  the  heterogeneous  mass  of  ])athological 
conditions  grouped  under  endometritis  to  exact  criticism,  much  would 
disappear  and  the  residuum  would  be  small.  Thus  endometritis  fungosa 
is  more  of  the  nature  of  a  new  growth  than  of  an  inflammatory  process; 
the  glandular  form  of  endometritis  is  iriore  akin  to  an  adenoma  than  to  a 


INFLAMMATION  OF   THE    UTERUS  191 


catarrh  of  a  mucous  membrane ;  and  many  cases  of  endometritis  after 
abortion  should,  according  to  Ktistner,  be  considered  as  deciduomas. 

Pozzi,  however,  in  his  admirable  chapter  on  Metritis  in  his  treatise 
on  Gynsecology,  justifies  the  grouping  of  these  varied  conditions  under 
Metritis,  because  they  have  these  features  in  common  —  that  their  com- 
mencement is  an  infective  process,  and  their  evolution  defensive  and 
limiting  in  its  action.  This,  however,  does  not  exhaust  the  features  of 
an  inflammation  as  contrasted  with  a  neoplasm.  The  final  product  of 
an  inflammatory  process  is  a  degenerated  tissue  rather  than  the  tissue 
characteristic  of  the  organ  in  which  it  has  occurred.  Of  the  former  we 
have  illustrations  in  those  forms  of  endometritis  which  end  in  the  de- 
struction of  the  mucosa ;  of  the  latter  in  those  which  end  in  hypertrophy. 

On  the  other  hand,  the  uterine  mucosa,  and  especially  that  of  the 
cervix,  is  analogous  to  other  mucous  membranes  in  its  tendency  to  be 
affected  in  certain  diatheses  or  constitutional  states.  Thus  in  tubercu- 
losis and  syphilis,  in  rheumatism  and  gout,  in  anaemia  and  chlorosis,  there 
is  a  tendency  to  cervical  catarrh  as  there  is  to  bronchial  or  gastric  catarrh. 

We  are  not  yet  in  a  position  to  classify  satisfactorily  the  causes  of 
uterine  inflammation.  All  we  can  do,  in  the  present  state  of  our  know- 
ledge, is  to  arrange  them  in  two  groups,  —  those  which  are  constitu- 
tional, and  those  which  are  local.  It  is  evident  that  this  classification 
is  not  satisfactory,  because  in  many  cases  the  factor  is  a  micro-organism 
which,  as  it  gains  access  through  the  mucous  membrane,  is  a  local  cause, 
but  in  so  far  as  the  whole  system  becomes  affected  by  it,  is  a  general 
cause. 

The  constitutional  causes  of  uterine  inflammation  are  even  more 
deserving  of  study  than  the  local  causes.  Being  less  obvious,  they  do 
not  force  themselves  upon  our  attention:  more  subtle  in  their  action, 
they  are  more  difliicult  to  estimate ;  and  the  more  their  constitutional 
quality,  the  more  difficult  they  may  be  to  treat.  In  scrofula  and  tuber- 
culosis there  is  a  tendency  to  uterine  catarrh,  affecting  specially  the 
cervix ;  as  there  is  a  tendency  in  the  same  diathesis  to  bronchial  or  gas- 
tric catarrh.  So  also  in  patients  suffering  from  rheumatism  and  gout,  we 
find  a  similar  tendency,  and  likewise  in  girls  suffering  from  anajmia  and 
chlorosis.  Apart,  indeed,  from  any  special  diathesis,  a  generally  en- 
feebled state  of  the  constitution  will  bring  out  tendencies  to  cervical 
catarrh,  as  it  may  to  tonsillitis.  Hence  the  gynaecologist  must  direct 
his  attention  to  those  modes  of  life  which  tend  to  undermine  the  health. 
Once  we  fully  appreciate  the  connection  between  the  general  health  and 
local  conditions,  we  shall  make  out  a  strong  case  against  the  current  mode 
of  bringing  up  young  girls,  especially  during  the  years  of  school  educa- 
tion. The  present  system  undoubtedly  favours  the  development  of 
menstrual  disturbances  which  frequently  end  in  uterine  inflammation. 

Passing  from  constitutional  states  to  specific  diseases,  we  find  that 
the  uterine  mucosa,  like  other  mucous  membranes,  is  affected  in  the 
course  of  the  exanthemata.  Thus  in  measles,  scarlatina,  and  small-pox, 
as  well  as  in  typhoid  fever  and  cholera,  endometritis  is  liable  to  occur. 


192  SYSl'EM  OF  GYN.-ECOLOGY 

In  the  recent  influenza  epidemic  nienorrliagia  was  a  not  infrequent 
symptom.  Gottsclialk  found  hcemorrliages  in  the  uterine  mucosa  iti 
influenza,  but'no  microbes.  Organic  diseases  wliich  favour  passive  con- 
gestion also  lead  to  inflammatory  changes  in  the  uterus.  Thus  in  dis- 
eases of  the  heart  and  kidney,  and  especially  of  the  liver,  uterine 
inflammation  may  he  present,  and  can  only  be  dealt  with  by  recognising 
and  treating  the  primary  affection. 

Inflammation  of  adjacent  organs  excites  inflammatory  changes  in  the 
uterus,  apart  from  simple  extension  of  inflammation.  This  occurs  in 
inflammation  of  the  uterine  appendages,  and  especially  of  the  ovaries. 
Czempin,  who  has  studied  this  point  in  patients  in  Dr.  Martin's  clinique 
in  Berlin,  mentions  four  kinds  of  such  causes :  inflammation  of  the  ova- 
ries with  or  without  that  of  the  tubes;  old  parametritis  which  has 
become  acute ;  irritation  of  the  peritoneum,  as  in  cicatrices  after  Tait's 
operation  and  ovariotomy ;  and  other  slowly  developing  conditions  of 
tiie  appendages,  such  as  pyosalpinx  and  sarcoma  of  the  ovary.  Should 
an  etiological  relationship  be  established  between  disease  of  the  appen- 
dages and  uterine  inflammation,  it  will  give  additional  reason  for  the 
removal  of  the  former  when  diseased. 

Irritation  of  the  rectum  also  keeps  up  uterine  inflammation,  and  the 
latter  has  been  known  to  disappear  on  removal  of  a  rectal  polypus. 

Passing  now  to  the  local  causes,  we  note  the  importance  of  exposure 
to  cold  or  great  fatigue  at  the  menstrual  period.  If  a  woman  take  a 
chill  during  menstruation  its  effects  will  probably  appear  in  the  pelvic 
organs.  And  apart  from  undue  exposure,  the  congestion  of  the  men- 
strual periods  plays  a  very  important  part  in  the  exacerbations  of  uterine 
inflammation. 

The  ovaries  play  a  special  part  in  the  development  of  endometritis. 
Brennecke,  who  has  drawn  attention  especially  to  this  point,  makes  one 
group  of  cases  of  endometritis  fungosa  arise  under  their  influence.  These 
cases  are  characterised  at  the  outset  by  amenorrhea  for  one  or  two  periods. 
This  he  explains  by  the  ovarian  stimulus,  which,  while  exciting  the  hy- 
pertrophy of  the  mucosa  which  precedes  normal  menstruation,  is  insuffi- 
cient to  cause  haemorrhage.  Thus  arises  a  hyperplasia  of  the  mucous 
membrane  from  which  haemorrhages  afterwards  occur.  I  have  not  seen 
any  cases  of  endometritis  beginning  with  pathological  amenorrhoea,  such 
as  Brennecke  describes,  but  have  always  been  able  to  account  for  the 
amenorrhoja  by  an  early  abortion.  On  the  other  hand,  the  irregular 
bleedings  at  puberty  point  to  a  tendency  to  endometritic  changes  in 
connection  with  the  initiation  of  the  functions  of  the  ovaries. 

Pelvic  congestion,  due  to  excessive  sexual  intercourse  or  to  mastur- 
bation, is  also  given  as  a  cause  of  uterine  inflammation.  In  prostitutes 
cervical  catarrh  is  common,  but  this  is  probably  the  result  of  gonorrhoea! 
infection. 

Septic  infection  occurs  usually  in  connection  witli  the  puerpei'iil  state, 
whether  after  aliortion  or  labour.  In  tliis  state  we  have  a  con il)i nation 
of  circumstances  favoui'alile  to  seijtic  infecticjn  ;  namely,  raw  surfaces, 


INFLAMMATION  OF  THE    UTERUS  193 

dead  matter  liable  to  decompose,  and  low  vitality  of  the  tissues.  It  is, 
therefore,  in  the  puerperal  state  that  we  find  the  best  examples  of  acute 
metritis,  and  in  connection  with  it  the  pathology  of  the  malady  has  been 
chiefly  studied.  Hence  acute  metritis  as  described  in  the  text-books 
concerns  the  obstetrician  rather  than  the  gynaecologist.  The  pathology 
of  the  chronic  forms  of  uterine  inflammation  which  come  under  the 
attention  of  the  gyucecologist  is  being  worked  out  but  slowly ;  they  are, 
however,  likewise  septic  in  origin.  This  is  a  fact  which  cannot  be  too 
much  insisted  on,  as  it  gives  the  reasons  of  the  treatment  which  is  here 
preventive,  and  consists  in  carrying  out  thorough  cleanliness  with  anti- 
sepsis in  all  gynaecological  work.  The  activity  of  germs  depends  in  yjart 
upon  the  media  in  which  they  are  cultivated.  Some  that  have  lost  their 
virulence  regain  it  in  a  favourable  soil.  And  the  post-partum  uterus  is 
practically  an  incubator,  at  a  suitable  temperature  for  their  develop- 
ment, containing  the  necessary  pabulum  in  the  form  of  retained  decidua 
or  blood-clot ;  we  can  therefore  understand  how  the  microbes  may  mul- 
tiply and  become  virulent  there.  Abortion,  even  more  frequently  than 
full-time  labour,  is  the  starting-point  of  uterine  inflammation,  owing  in 
part  to  the  greater  tendency  to  retention  of  portions  of  the  ovum,  and 
in  part  to  the  fact  that  patients  do  not  take  the  same  care  of  themselves 
after  abortion.  Lacerations  of  the  cervix  [see  "Morbid  Conditions  of 
the  Female  Genital  Organs  resulting  from  Parturition"  in  this  System], 
which  occur  in  abortion  as  in  labour,  form  channels  for  septic  absorption 
and  consequent  cervical  catarrh  ;  and  in  a  large  proportion  of  cases  we 
may  trace  the  inflammation  back  to  such  causes.  The  interior  of  the 
uterus  after  delivery  also  is  practically  a  large  raw  surface ;  hence  en- 
dometritis in  multiparas  can  often  be  traced  back  to  the  puerperium. 
The  term  subinvolution,  introduced  by  Sir  James  Simpson,  covers  all 
the  changes  in  the  cervix,  the  endometrium,  and  the  body  of  the  uterus 
thus  produced  during  this  period. 

Besides  acting  as  foci  for  the  production  of  septic  material,  portions 
of  retained  decidua  occasionally  cause  endometritis  by  maintaining  their 
vitality  instead  of  breaking  down  in  the  lochia.  In  such  cases  islets  of 
decidual  cells  have  been  described  in  the  inflamed  endometrium.  We 
have  thus  a  form  of  endometritis  after  abortion  which  is  a  new  formation 
rather  than  an  inflammation,  and  wliicli  can  only  be  treated  by  the 
curette. 

The  introdiiction  of  septic  matter  by  the  gynaecologist  in  his  use  of 
septic  sounds  or  tents,  or  the  neglect  of  antiseptics  in  operations,  need 
only  be  mentioned  as  sources  of  uterine  inflammation  which  should  not 
exist,  and  which  are  becoming  rarer  as  the  importance  of  antiseptics  is 
generally  recognised. 

If  in  fertile  women  puerperal  sepsis  is  the  most  important  cause  of 
uterine  inflammation,  in  sterile  women  the  ravages  of  the  gonococcus  are 
deserving  of  careful  study.  "While  those  who  have  written  on  gonorrhcea 
certainly  convey  the  impression  of  exaggerating  its  frequency,  it  is 
nevertheless  a  malady  which,  in  its  subtle  invasion  and  its  far-reaching 

o 


194  SYSTEM  OF  GYNECOLOGY 

effects,  requires  careful  investigation.  Of  these  effects  sterility  is  tlie 
most  important.  When  patients  seek  advice,  many  years  after  marriage, 
on  account  of  barrenness,  persistent  leucorrhoea,  menorrhagia,  and  dys- 
menorrhoea,  symptoms  all  dating  from  the  time  of  marriage,  the  possi- 
bility of  gonorrhoeal  infection  must  be  kept  in  mind.  Here  also  we  note 
the  importance  of  the  etiological  standpoint ;  for  if  we  can  be  sure  of 
the  cause,  the  whole  case,  as  regards  both  diagnosis  and  treatment, 
assumes  a  different  complexion. 

Uterine  inflammation  as  the  result  of  displacements  is  of  interest, 
as  it  gives  us  the  clue  to  the  difference  in  the  opinions  of  gynaecologists 
concerning  the  significance  of  these  lesions.  Where  retroversion  has 
not  interfered  with  the  involution  of  the  uterus  during  the  puerperium 
the  displacement  is  symptomless ;  but  if  endometritis  and  chronic  me- 
tritis be  present,  we  have  then  symptoms  due  to  these  pathological 
conditions.  Chronic  metritis  and  endometritis  are  by  no  means  such 
invariable  accompaniments  of  retroversion  as  they  are  of  prolapse,  in 
which  there  is  always  some  hypertrophy  due  to  their  presence.  For 
the  full  discussion  of  the  relation  of  displacement  to  inflammatory  con- 
ditions, see  the  chapter  of  this  work  on  "  Displacements  of  the  Uterus." 

Chronic  metritis  and  endometritis  also  accompany  fibroid  tumours 
of  the  uterus  and  mucous  polypi,  as  described  in  the  chapter  on  "Simple 
Growths  of  the  Uterus." 

We  pass  now  to  the  various  forms  of  inflammation,  dividing  them, 
according  to  the  seat  of  the  lesion,  into  (A)  Cervical  catarrh ;  (B)  Endo- 
metritis; and  (C)  Metritis. 

The  cervix  is  sufficiently  distinct  from  the  body  of  the  uterus  to 
justify  its  being  treated  separately.  Structurally  it  is  quite  different 
from  the  latter  :  on  its  vaginal  aspect  it  is  covered  with  squamous 
epithelium  resting  on  papillae  of  connective  tissue,  and  without  mucous 
follicles ;  its  canal  is  lined  with  a  single  layer  of  cubical  epithelium  so 
folded  as  to  form  shallow  recesses  with  racemose  mucous  glands ;  its 
laucous  surface  differs,  therefore,  from  that  lining  the  body  of  the 
uterus.  Its  muscular  tissue  is  not  arranged  in  layers,  but  consists  of 
fibres  scattered  irregularly  through  the  connective  tissue  which  prepon- 
derates. Functionally,  it  differs  from  the  body  in  that  it  plays  a  passive 
part  in  menstruation  and  pregnancy.  Pathologically,  it  ditt'ers  in  that 
the  tumours  which  are  common  in  it  are  rare  in  the  body  of  the  uterus, 
and  conversely.  We  are  therefore  prepared  for  the  fact  that  chronic 
inflammation  of  the  cervix  may  not  spread  to  the  body  of  the  uterus. 
Though  clinically  we  frequently  find  cervicitis  accompanied  by  inflam- 
mation of  the  body,  yet  the  fact  that  this  association  does  not  by  any 
means  invariably  occur  warrants  our  considering  the  cervix  by  itself. 

An  anatomical  and  pathological  basis  for  classification  oi  the  various 
forms  of  uterine  inflammation  is  pref(!rable  to  a  purely  clinical  one.  As 
an  illustration  of  the  latter,  we  have  Pozzi's  classification  according  to 
"the  dominant  clinical  characteristic."  lie  thus  descriljcs  (i.)  Acute 
inflammatory  metritis;  (ii.)  Haemorrhagic  metritis;  (iii.)  Catarrhal  me- 


INFLAMMATION   OF   THE    UTERUS  195 

tritis ;  (iv.)  Chronic  painful  metritis.  Wliile  agreeing  with  all  that  he 
says  as  to  the  artificial  nature  of  the  various  classifications  of  varieties 
of  uterine  inflammation,  and  agreeing  with  him  also  on  the  importance 
of  the  clinical  standpoint,  we  question  whether  merely  to  select  a  promi- 
nent symptom  as  the  basis  of  classification,  is  an  advance  in  our  method 
of  classification.  Though  much  can  be  said  in  its  favour,  it  is  practi- 
cally to  return  to  the  symptomatological  standpoint  regarding  disease. 

A.  Chronic  Cervical  Catarrh.  —  Acute  cervical  catarrh  can  sel- 
dom be  studied  as  a  separate  condition.  It  occurs  as  part  of  the  general 
inflammation  of  the  uterus  seen  in  puerperal  sepsis,  and  is  often  tlie  initial 
stage  of  the  chronic  affection,  from  which,  however,  it  is  not  marked  off. 

Chronic  cervical  catarrh  is  one  of  the  most  important  conditions  which 
the  gynaecologist  has  to  treat.  Matthews  Duncan  said  that,  according  to 
its  gravity,  it  Avould  not  be  placed  higher  than  the  third  rank ;  but  that 
on  account  of  its  frequency  it  ranks  with  chronic  ovaritis  and  chronic 
inflammation  of  the  uterus. 

Clinical  History  and  Symptoms.  —  The  patient,  usually  a  multipara, 
comes  complaining  of  a  weak  back  and  "  whites."  The  pain  is  generally 
found  to  be  in  the  sacral  region,  the  seat  of  sympathetic  pain  for  the  cer- 
vix; sometimes  it  is  a  sense  of  dragging  or  bearing  down  on  the  pelvis. 

The  white  discharge  may  simply  be  an  exaggeration  of  the  normal 
secretion  of  the  cervix,  which  is  viscid  and  opalescent,  or  it  may  be 
yellow  and  purulent.  In  the  former  case  it  is  difficult  to  draw  the  line 
between  the  normal  and  the  morbid,  as  many  women  normally  have  a 
certain  amount  of  leucorrhoeal  discharge,  especially  after  the  menstrual 
period.  The  discharge  may  have  probably  lasted  some  time,  unless 
suddenness  of  onset  with  urinary  symptoms,  which  is  often  suggestiv^e  of  a 
gonorrhoeal  origin,  lead  her  to  seek  advice  at  once.  The  most  striking 
feature  of  cervical  catarrh  is  its  chronic  character ;  the  condition  is  one 
which  sometimes  lasts  for  years.  The  patient  may  show  one  of  the  con- 
stitutional conditions  referred  to  under  etiology,  such  as  anaemia  or  the 
gouty  diathesis ;  and  the  more  remote  causes  leading  to  the  congestion  of 
the  uterus,  as  of  other  organs,  should  always  be  inquired  into.  The 
symptoms  will  most  frequently  be  traced  back  to  child-birth  or  abortion, 
sometimes  to  exposure  to  cold  or  undue  fatigue  at  a  menstrual  period,  or 
to  the  commencement  of  gonorrhoeal  infection.  In  acute  cases  urinary 
complications  are  often  present.  Menstruation  is  some  times  profuse  and 
painful,  which  is  probably  due  to  accompanying  endometritis  —  just  as 
the  pain  in  sexual  intercourse,  which  is  sometimes  complained  of,  may 
be  explained  by  associated  parametritis ;  the  cervix  uti>ri  itself  is  not 
sensitive.  If  the  condition  have  persisted  for  a  long  time  symptoms  of 
general  weakness  come  on.  The  patient  complains  of  lack  of  energ}-  and 
of  being  easily  tired,  and  she  may  have  a  poor  appetite  and  slow 
digestion.  Sterility  is  also  present  in  some  cases,  although  it  is  difficult 
to  say  whether  this  is  due  to  a  plug  of  mucus  in  the  cervix  or  to  some 
affection  of  the  mucous  monibi'ano  hiHior  up  in  the  >j:Piiital  tract.     The 


196  SVSTEJ/  OF  GYNAECOLOGY 

explanation  of  the  sterility  is  more  probably  vital  than  mechanical, 
as  the  discharge  affects  the  vitality  of  the  spermatozoa. 

Pathology  in  Relation  to  Physical  Signs. — Pathology  renders  a 
peculiar  service  to  the  clinician  in  giving  him  a  basis  for  physical  diag- 
nosis. It  accounts  for  appearances  which  he  has  noticed  clinically.  The 
study  of  disease  is  the  study  of  a  life  history.  At  each  successive  stage 
in  its  progress  the  pathologist  steps  in  and  gives  a  physical  basis  for  each 
sign  and  symptom.  He  clears  away  the  crumbling  remnants  of  a  broken- 
down  hypothesis,  and  enables  the  clinician  to  jDut  his  foot  down  on  the 
rock  of  anatomical  fact.  We  consider  pathology,  therefore,  in  its  relation 
to  physical  signs. 

Nowhere  has  this  service  of  pathology  been  more  strikingly  illustrated 
than  in  the  physical  diagnosis  of  cervical  catarrh.  The  use  of  the  speculum 
to  determine  the  source  of  the  discharge  shows  a  red  granular  surface 
round  the  os  externum,  which  bleeds  easily.  Though  more  difficult  to 
use,  Sims'  speculum  is  superior  to  either  the  bivalve  or  tubular  one, 
because  it  disturbs  less  the  normal  condition  of  the  parts,  and  enables  us 
to  judge  of  the  presence  of  laceration  and  the  amount  of  ectropion. 

The  surface  looks  like  an  ulcer,  because  it  is  red,  granular,  and 
bleeds ;  and  looking  like  an  ulcer  it  was  called  an  ulcer,  and  treated  by 
surgical  methods  as  ulceration.  Notions  derived  from  ulceration  of  the 
skin  were  imported  into  the  region  round  the  os ;  and  herpes,  pemphi- 
gus, varicose  ulcers,  and  cockscomb  granulations  were  described.  The 
condition  round  the  os  was  dissociated  from  the  catarrhal  inflamma- 
tion within  the  canal,  or  was  regarded  as  secondary  to  it,  the  irritating 
leucorrhoea  causing  destruction  of  tissue.  The  term  ulceration  not  only 
suggested  a  wrong  treatment,  but  gave  the  condition  an  imdue  impor- 
tance in  the  mind  of  the  patient. 

All  this  was  changed  by  the  microscopic  work  of  Ruge  and  Veit  (30), 
wlio  showed  that  the  apparently  raw  surface  is  covered  with  epithelium, 

and  that  the  granular  points  are  new 
formations  which  have  no  relation  to  the 
granulations  of  an  ulcer.  The  micro- 
scopic characters  of  the  mucous  mem- 
brane, to  be  readily  understood  from  Fig. 
f)     .'•;       ,  -  -    ,     44,  which  represents  a  clipping  from  one 

W     3  -^    i'i^^'^'*-^  '     of  these  catarrhal  patches,  are  as  follows. 
*»     e'.^.y/l    ,»  #     ^Wi^nrih  The  surface  is  covered  with  a  single  layer 

of  epithelium,  the  cells  are  smaller  than 
those  which  line  the  normal  cervical 
canal,  and  being  narrow  and  long,  have 
a  palisade-like  arrangement.     The  thin 

the  cervix.     The  free  surface  Ih  covere.l  .  f       ||^  alloWS  tlu!  Subiaceut  VaSCU- 

with  a  Hlri(fle  layer  of  columnar  epithe-         .'  i   •  i  i     V 

Hum.     It  Is  folded   Into  papillary  eleva-  liU' tisSUC  to  shllU!  through,  IkMICC  the  red 

tlons.    Below  the  surface  are  (?lan.l2«.o..s  .^^.,.,^.^y.^^^,,^^  of  the  SUrfa(!C.      The  SUrfaCC 

cut  across  whlcti  may  becorno  dilated  so  "^"r  1'    >«'>•' 

as  to  fr.rm  retention-cysts.  is  further  tlirown  into  numcrous  folds 

producing  glandular  recesses  and  processes.     These  processes  cause  the 


INFLAMMATION   OF  THE    UTERUS  197 

granular  appearance  of  the  surface.  If  the  recesses  be  long  and  narrow, 
the  surface  is  split  up  into  distinct  papillae.  This  constitutes  the  papil- 
lary erosion.  If  the  ducts  of  the  glandular  recesses  become  obliterated, 
the  secretion  distends  the  glands  below  and  produces  retention-cysts ; 
these  increase  in  size,  and  may  come  to  the  surface  and  burst.  Thus  is 
formed  the  follicular  erosion. 

The  raw-looking  surface  is  therefore  a  newly  formed  glandular 
secreting  surface,  Avhich  in  structure  resembles  the  cervical  mucous 
membrane.  This  addition  to  the  extent  of  secreting  surface  increases 
the  leucorrhoeal  discharge,  which  is  the  leading  symptom.  The  so-called 
ulceration  is  thus  seen  to  be  simply  a  part  of  the  process  of  cervical 
catarrh,  and  this  not  the  most  important  part.  If  the  cervix  have  been 
lacerated  the  swollen  mucous  membrane  causes  a  gaping  of  the  cervi- 
cal canal  at  the  cleft ;  and  thus  we  may  be  misled  as  to  the  extent  to 
which  the  catarrhal  patches  spread  beyond  the  os  externum.  By  roll- 
ing in  the  everted  lips  with  the  tenacula  until  the  laceration  closes  we 
can  estimate  the  probable  position  of  the  os  externum. 

From  this  it  is  evident  that  the  process  is  not  one  of  ulceration, 
and  the  term  should  be  abandoned.  The  German  term  "  erosion "  is 
open  to  similar  objections.  "Ectropion"  or  "eversion"  of  the  mucous 
membrane  describes  the  condition  in  its  relation  to  laceration,  but 
does  not  describe  the  extension  of  the  secreting  surface  beyond  the 
OS  externum.  The  term  is  perferable  to  ulceration,  however,  as  it  is  not 
so  misleading.  Thomas  describes  these  conditions  under  the  name 
of  granular  and  cystic  degeneration  of  the  cervix  uteri,  and  Palmer 
makes  a  compromise  between  the  new  and  the  old  by  treating  of  them 
under  the  title  of  "ulcerations  and  degenerations  of  the  cervix  uteri.'' 
We  are  not  yet  in  a  position  to  introduce  a  term  based  on  pathology, 
even  if  it  were  desirable  to  give  to  this  appearance  a  special  name,  and 
thus  to  suggest  a  difference  in  nature  from  the  inflamed  mucous  mem- 
brane in  the  canal.  Probably  the  best  name  for  these  red  patches 
lying  outside  the  os  externum  is  "  catarrhal  patches,"  as  it  suggests 
that  they  are  portions  of  the  mucous  membrane  in  the  same  catarrhal 
condition  as  that  lining  the  cervical  canal. 

Fischel  and  other  observers  have  confirmed  these  observations  of 
Euge  and  A^eit  in  their  essential  points.  Pischel  considers,  however, 
that  the  secreting  processes,  though  new  formations,  have  the  structure 
of  papillce,  and  are  not  mere  foldings  of  the  mucous  membrane. 

While  there  is,  therefore,  no  disagreement  as  to  the  microscopic 
appearance  of  the  so-called  "  ulcerations,"  the  origin  of  this  new  epithelial 
structure  is  disputed.  Euge  and  Veit  hold  that  this  single  layer  of  small 
cylindrical  cells  is  produced  by  proliferation  of  the  cells  of  the  deepest 
layer  of  the  rete  Malpighi,  while  those  of  the  superficial  layer  are  shelled 
off.  It  will  be  observed  also  that  they  regard  the  simple  follicular  and 
papillary  "ulcerations"  as  the  results  of  one  and  the  same  process, 
namely,  proliferation  of  epithelial  cells.  On  the  other  hand,  those  rod 
patches  are  generally  continuous  with  the  mucous  membrane  of  the  cer- 


igS  SYSTEM   OF  GYNECOLOGY 

vical  canal,  aud  resemble  it  iu  their  microscopic  structure.  It  is  therefore 
much  more  probable  that  they  are  occasioned  by  proliferation  of  the  epi- 
thelium which  lines  the  cervical  glands,  leading  to  an  extension  of  the 
glandidar  surface  beyond  the  os  externum.  Fischel  holds  that  there 
is  not  only  a  proliferation  of  epithelial  cells,  but  of  connective  tissue 
also,  and  that  as  the  one  or  the  other  preponderates  the  follicular  or 
papillary  forms  are  produced.  He  also  thinks  that  erosions  are  due  to 
the  persistence  of  the  cylindrical  epithelium  (found  outside  the  os 
externum  in  the  foetus)  into  adult  life,  and  to  the  desquamation  of  the 
squamous  epithelium  which  had  come  to  cover  it. 

The  question  of  the  origin  of  the  cylindrical  epithelium  found  iu 
erosions  is  rendered  more  difficult  by  the  fact  that  the  boundary-line 
between  the  squamous  epithelium  outside  the  cervical  canal  and  the 
cylindrical  within  it  varies  at  different  periods  of  development  and  in 
different  individuals.  In  the  foetus,  according  to  Ruge's  investigations, 
the  cylindrical  epithelium  extends  beyond  the  os  externum ;  and  we  have 
a  hint  of  the  persistence  of  this  foetal  condition  in  the  congenital  ectro- 
pion described  by  Fischel.  Klotz  describes  two  types  of  cervix  distin- 
guished by  the  distribution  of  the  squamous  epithelium  :  one,  cavernous 
in  texture,  and  having  the  squamous  epithelium  extending  some  distance 
into  the  cervix;  the  other,  glandular  in  its  substance,  and  having  the 
squamous  epithelium  stopping  at  the  usual  seat  of  the  os  externum. 

The  foregoing  description  is  based  on  what  is  found  in  multiparous 
patients  in  whom  the  cervical  changes,  as  seen  through  the  speculum,  are 
obvious.  In  nulliparous  patients  cervical  catarrh  may  manifest  itself 
bv  catarrhal  patches  beyond  the  os  externum,  but  more  frequently  the 
vaginal  aspect  of  the  cervix,  though  soft  and  swollen,  looks  healthy. 
The  mucous  membrane  within  the  canal,  however,  is  in  a  similar  con- 
dition to  that  described  above.  The  os  is  sometimes  unusually  small, 
and  the  cervical  canal  becomes  distended  with  the  secretion. 

The  diagnosis  of  cervical  catarrh  is  comparatively  easy,  the  cervix 
l)eing  accessible  to  examination.  The  condition  found  on  vaginal  examina- 
tion varies  as  the  patient  is  a  nullipara  or  a  multipara.  In  the  former  case 
the  cervix  feels  enlarged  and  softened,  and  when  there  is  extension  of  the 
catarrhal  area  beyond  the  os  extermim  the  margins  of  the  os  are  soft  and 
velvety.  In  a  multipara  the  os  will  probably  be  notched  by  old  lacerar 
tions,  and  may  be  so  patent  that  the  tip  of  the  finger  can  be  passed  into 
the  cervical  canal  The  area  round  the  os  is  soft  and  velvety,  or  rough 
and  granular;  and  when  the  Kabothian  follicles  have  been  converted 
into  retention  cysts,  these  are  felt  as  small  nodules,  like  peas  or  shot, 
in  the  mucous  memVH-ane.  Polypoidal  projections  may  be  present,  and, 
more  rarely,  the  whole  cervix  is  converted  into  a  cystic  mass.  The 
speculum  can  now  be  used  to  confirm  what  tlio  fingers  have  felt,  and 
is  aV)Solutely  necessary  in  training  the  finger  to  recognise  the  various 
conditions  present.  The  extent  of  catarrhal  area,  the  amount  of  eversion, 
and  tlie  ajjpearances  corresponding  to  the  velvety,  granular,  and  nodular 
(■(•('lings  are  demonstrated  Vjy  it.     I>iit  once  the  finger  has  been  educated. 


INFLAMMATION   OF   THE    UTERUS  199 

the  speculum,  for  diagnosis  at  any  rate,  comes  to  be  less  and  less  used. 
When  it  is  desirable  to  determine  the  extent  of  lacerations  with  a  view 
to  operative  procedure,  tenacula  are  useful  to  roll  in  the  everted  lips 
of  the  cervix.  The  sound  is  only  of  service  in  diagnosing  catarrh  in 
nulliparae,  where  it  may  show  a  cervical  canal  unusually  dilated  by 
accumulated  secretion. 

Under  differential  diagnosis  we  have  only  to  consider  the  diagnosis  of 
cervical  from  vaginal  or  uterine  leucorrhoea,  and  of  simple  induration  of 
the  cervix  from  syphilitic  ulceration  and  commencing  malignant  disease. 

The  normal  secretion  from  the  glands  of  the  cervical  canal  is  clear  and 
viscid,  resembling  unboiled  white  of  egg;  and  it  is  alkaline  in  reaction. 
It  may  be  of  an  opaque  white  due  to  an  escape  of  mucous  corpuscles,  or 
yellow  Avhen  pus  corpuscles  are  present.  Frequently  it  is  tinged  with 
blood.  In  the  worst  cases  of  catarrh  the  discharge  is  a  thin  j-ellow  or 
greenish  pus.  The  diagnosis  of  cervical  from  vaginal  leucorrhoea  is  made 
by  the  speculum,  for  in  the  former  case  we  see  the  leucorrhoea,  with  the 
characters  above  mentioned,  coming  from  the  cervix ;  or  by  Schultze's 
method  of  placing  a  tampon  at  the  os  externum  to  catch  the  cervical  secre- 
tion. The  diagnosis  of  cervical  from  uterine  leucorrhoea  is  more  difficult. 
Menorrhagia,  with  increase  in  the  length  of  the  uterine  cavity  and  irregu- 
larities in  its  mucous  membrane,  point  to  the  presence  of  endometritis. 

Syphilitic  ulceration  of  the  cervix  is  extremely  rare,  and  the  history, 
with  the  indications  of  syphilis  in  other  parts,  makes  diagnosis  easy. 
On  the  other  hand,  the  diagnosis  from  commencing  malignant  disease 
is  exceedingly  difficult.  If  we  are  dealing  with  a  case  of  advanced  car- 
cinoma, in  which  ulceration  has  occurred,  there  is  no  difficulty;  the 
finger  at  once  recognises  the  friable  bleeding  surface  with  firmer  mar- 
gins, and  the  infiltration  of  the  cellular  tissue  causing  fixation.  If,  how- 
ever, the  cervix  be  simply  nodular,  and  ulceration  has  not  occurred,  it 
may  be  impossible  to  say  at  this  stage  whether  the  case  be  one  of  cancer 
or  not.  Bennet  drew  attention  to  the  fact  that  the  lobulation  of  the 
cervix  in  chronic  inflammation  was  more  regular,  the  furrows  radiating 
from  the  cervical  canal  being  in  fact  old  lacerations,  while  in  cancer  the 
lobulations  are  irregular.  According  to  Spiegelberg,  when  a  tent  is 
placed  in  a  cervix  affected  with  malignant  disease  the  infiltrated  parts 
do  not  dilate  like  normal  tissue.  This  subject  belongs,  however,  to  the 
diagnosis  of  commencing  cancer,  for  which  the  chapter  of  this  work  on 
"  Malignant  Diseases  of  the  Uterus  "  must  be  consulted. 

Treatment.  —  The  importance  of  constitutional  treatment  must  be 
fully  recognised,  as  there  is  no  doubt  that  far  too  much  attention  has 
been  given  to  local  treatment.  In  most  essays  on  the  treatment  of  cer- 
vical catarrh  Ave  find  pages  given  to  local  applications  and  to  operative 
procedure,  while  general  treatment  is  dismissed  in  a  paragraph.  This 
makes  the  local,  as  against  the  general  treatment,  bulk  far  too  largely  in 
the  mind  of  the  practitioner.  While,  on  the  one  hand,  it  may  be  argued 
that  there  will  always  be  a  class  of  patients  who  are  not  satisfied  unless 
something  is  being  done  directly  for  them,  we  must  remember  that,  on 


SYSTEM   OF   GYXyECOLOGY 


the  other  hand,  irreparable  harm  often  results  from  lines  of  treatment 
■which- direct  the  patient's  attention  to  the  pelvic  organs. 

The  care  of  the  patient's  general  health  is  to  be  put  in  the  forefront. 
Change  of  air,  light  nourishing  food,  and  a  certain  amount  of  exercise 
are  beneficial ;  and  cold  hip-baths  in  the  morning  are  of  service.  Dis- 
turbances of  the  digestive  system,  which  are  frequent  in  chronic  cases, 
must  be  carefully  treated.  Where  rest  from  sexual  activity  is  desirable, 
this  is  often  secured  by  recommending  that  the  patient  leave  home  for 
a  time.  Tonics,  such  as  arsenic,  quinine,  and  iron,  are  useful.  Sir  James 
Simpson  recommended  arsenic,  believing  that  it  acted  beneficially  on  the 
cervix  as  it  does  on  skin  eruptions. 

The  diathesis  should  also  be  carefully  studied.  In  strumous  or  gouty 
patients,  for  example,  cervical  catarrh  is  simply  one  of  many  manifesta- 
tions of  the  constitutional  state,  and  is  only  of  significance  as  directing 
our  attention  to  it. 

Of  local  applications  the  most  important  is  the  vaginal  douche.  This 
treatment,  as  well  as  the  mode  of  applying  various  therapeutic  agents  to 
the  uterus,  is  described  in  the  chapter  on  ''  Gynaecological  Therapeutics  " ; 
so  that  here  mention  need  be  made  only  of  special  points  bearing  on  their 
use  in  uterine  inflammation.  The  douche,  to  be  effective,  should  be  given 
by  means  of  a  douche-can,  and  consist  of  not  less  than  a  quart  of  water. 
The  patient  should  be  semi-recumbent.  The  temperature  of  the  water 
must  be  adapted  to  the  individual  case :  if  pain  or  haemorrhage  be  pres- 
ent the  hot  douche  is  preferable.  The  douche  is  given  for  cleanliness, 
and  for  the  application  of  antiseptics  and  astringents.  Corrosive  subli- 
mate (1  to  40U0)  is  very  useful  in  chronic  catarrh,  especially  if  a  gonor- 
rhoeal  or  septic  taint  be  suspected.  Sulphate  of  zinc  (1  dr.  to  a  pint), 
sulphate  of  alumina  or  sulphate  of  copper  (2  drs.  to  a  pint),  are  also 
beneficial.  The  action  of  these  on  the  catarrhal  patches  has  been 
specially  investigated  by  Hofmeier,  who  found  that  the  pale,  squamous 
epithelium  gradually  crept  in  tongue-like  processes  over  the  red  patch. 
Fig.  45  shows  how  the  superficial  glands  become  filled  up  with  squamous 
epithelial  cells.  The  deeper  glands  have  their  ducts  narrowed  or  even 
plugged  while  the  gland  cavity  persists  below.  Kiistner  found  similar 
changes  ^jroduced  by  antiseptic  douches. 

Medicaments  may  also  be  applied  on  vaginal  tampons,  the  best 
excipient  being  glycerine.  The  glycerine  itself  acts  by  withdrawing 
serum  from  the  engorged  tissue.  To  it  may  be  added  boric  acid  (50 
per  centj,  tannin  (1  dr.  to  1  oz.),  ichthyol  (10  per  cent),  and  iodoform. 

Applicatifnis  may  also  be  made  on  forceps  dressed  with  cotton  wad- 
ding, dry  wadding  being  used  first  to  swab  off  the  mucus.  Churchill 
used  a  preparation  of  iodine  consisting  of  75  grains  of  iodine  and  90  of 
potassium  iodide  in  1  ounce  of  alcohol.  Weak  solutions  of  nitrate  of 
silver  are  also  beneficial. 

Where  the  cervix  is  much  indurated  and  studded  with  retention- 
cysts,  scarification  is  very  useful;  it  acts  Ijy  dejdetion,  and  also  by  let- 
ting out  the  inspissated  mucus.     Bleeding  by  scarification  has  largely 


INFLAMMATION   OF   TIIF    UTERUS 


taken  the  place  of  leeching.  Various  scarificators  have  been  devised, 
but  an  ordinary  bistoury  does  perfectly.  A  tepid  douche  given  after- 
wards promotes  bleeding.  Scarification  is  preferable  to  tlie  actual 
cautery,  which  has  been  recommended  by  Prochownik,  as  the  latter  is 
followed  by  cicatrisation.  In  very  chronic  cases  the  only  remedy  is  to 
destroy  the  diseased  glands,  as  we  excise  the  tonsils  in  tonsillitis :  this 
is  done  by  caustics,  the  curette,  or  the  knife.  Of  caustics,  potassa-fusa 
was  recommended  by  Sir  James  Simpson,  and  the  zinc-alum  sticks  of 
Skoldberg  by  Matthews  Duncan.  This  use  of  caustic  must  be  distin- 
guished from  the  application  of  it  to  touch  the  so-called  ulcer  so  as  to 
make  it  heal,  and  has  many  advocates.  It  is  better  to  use  the  curette, 
as  recommended  by  Thomas,  or  the  knife  as  in  Schroeder's  operation 
(32).     In  fact,  where  the  glandular  tissue  has  to  be  destroyed,  the  most 


Fig.  45.  —  Healinfr  of  a  catarrhal  patch  treated  by  astringent  or  antiseptic  injections  (Hofmeier").  From 
C  to  &  is  seen  part  of  a  catarrhal  patch  (compare  Fig-.  44)  which  from  b  to  a  has  become  covered 
over  with  newly  formed  squamous  epithelium  ;  dd,  glauds  whose  ducts  have  been  obliterated  ; 
c,  gland  duct  which  has  persisted. 


efficient  and  cleanest  way  of  doing  it  is  by  excision  of  the  mucous  mem- 
brane, although  the  cases  in  which  this  operation  is  called  for  are  com- 
paratively rare.  In  Schroeder's  operation  the  cervix  is  laid  hold  of  by 
two  volsellffi,  one  on  each  lip,  and  drawn  downwards.  It  is  then  divided 
laterally,  as  far  as  the  fornix,  with  the  scissors,  so  as  to  form  an  anterior 
and  posterior  lip  which  are  separated  as  far  as  the  vaginal  roof.  A  trans- 
verse incision  (seen  in  section  at  a,  in  Fig.  4G)  is  made  across  the  base  of 
the  anterior  lip  dividing  the  whole  thickness  of  cervical  mucous  mem- 
brane. The  point  of  the  lip  is  next  pierced  at  c,  and  the  knife  pushed 
in  the  direction  hh  till  it  reaches  the  cross  incision  a ;  the  blade  is  then 
carried  outwards,  first  to  the  one  side  and  then  to  the  other,  so  that  all 
outside  of  the  line  a,  6,  c  is  removed.  The  flap  of  the  cervix  is  now 
turned  in  and  stitched  (Fig.  47),  and  the  angles  of  the  wound  in  the 
fornix  closed. 

Emmet's  uperatiou  is  also  useful  in  cases  of  deep  laceration,  espe- 


SYSTEM   OF  GYNECOLOGY 


cially  where  there  is  cicatricial  tissue  at  the  base  of  the  cleft :  it  has  not 
fulfilled  all  that  was  expected  of  it,  however,  aud  it  is  not  performed 
nearly  so  frequently  as  was  the  case  some  years  ago.  It  simply  conceals, 
without  removing  the  diseased  mucous  membrane,  and  should  always  be 
combined  with  measures  directed  to  the  treatment  of  the  catarrh. 

For  marked  hypertrophy  of  the  substance  of  the  cervix  amputation 
is  the  only  treatment. 

In  the  cervical  catarrh  of  nulliparae,  where  there  is  a  narrow  us 
externum,  the  bilateral  division  of  the  cervix  is  of  service.  It  allows 
the  secretion  to  escape  instead  of  accumulating ;  and  applications  can 
be  made  to  the  cervical  canal.  It  is  also  said  to  favour  the  occurrence 
of  conception. 

These  operations  are  described  in  the  chapter  on  "  Plastic  Gynaeco- 
logical Operations." 


KiG.  40. 


Fig.  47. 


Bchroeder's  operation  for  excision  of  the  cervical  mucous  membrane  in  cervical  catarrh.  Fig.  4fi, 
line  of  incision  in  mucous  membrane  ;  Fig.  47,  mucous  membrane  excised,  and  flap  6c  turned  in 
on  ah. 


Acute  Metritis  and  Endometritis. — In  the  acute  condition  we 
cannot  separate  these  two  affections.  Clinically  they  are  met  with  in 
the  puerperal  state,  and  as  exacerbations  of  the  chronic  condition  to  be 
described  presently.  Except  in  the  puerperal  state  they  are  never  fatal, 
and  hence  the  classical  descriptions  which  are  handed  from  text-book  to 
text-book  belong  to  a  treatise  on  puerperal  fever  ratlier  than  to  a  system 
of  gynaicokjgy. 

Wyder  (44),  from  a  study  of  the  membrane  exfoliated  in  cases 
of  membranous  dysmenorrhoea,  has  recently  described  the  pathological 
changes  which  he  regards  as  those  of  acute  endometritis.  The  cells  in 
the  stroma  are  greatly  increased  in  numbers,  and  are  so  closely  packed 
together  that  little  of  the  matrix  is  seen.  Cxottschalk,  on  the  other 
hand,  finds  in  the  exfoliated  membrane  changes  characteristic  of  a 
haimorrhagic  interstitial  endometritis.  Membranous  dysmenorrhoea,  or, 
as    it   has    been   called,   (!xfoli;itiv(;    (indometritis,   is  a  rare  affection, 


INFLAMMATION   OF   THE    UTERUS  203 

and  its  pathology  can  hardly  be  considered  to  be  the  same  as  that  of 
acute  endometritis. 

B.  Chronic  Exdometkitis.  —  This  is  a  sufficiently  well-marked  con- 
dition to  merit  separate  treatment.  I  would  limit  the  term  to  those  cases 
in  which  the  patient  has  the  general  symptoms  of  chronic  uterine  inflam- 
mation, Avhich  I  shall  describe  under  chronic  metritis,  with  in  addition 
increased  discharge  either  of  blood  at  the  menstrual  period,  or  of  leucor- 
rhoea  in  the  intervals.  As  the  presence  of  either  of  these  symptoms 
points  to  changes  in  the  uterine  mucosa  as  the  more  prominent  condition, 
there  is  sufficient  reason  for  treating  chronic  endometritis  as  a  condition 
distinct  from  chronic  metritis. 

Clinical  History  and  Symptoms The  history  may  be  traced  back  to 

abortion  or  labour,  to  an  attack  of  uterine  inflammation  as  the  result 
of  chill,  or  to  gonorrhoeal  infection.  In  a  considerable  number  of  cases, 
however,  the  symptoms  begin  insidiously,  and  develop  gradually  with- 
out any  assignable  cause.  Endometritis  is  more  frequent  in  multiparous 
patients,  and  more  common  later  than  earlier  in  life ;  though  it  also 
occurs  in  nulliparae,  especially  when  there  is  stenosis  of  the  os  externum. 
Huge  describes  one-half  of  his  cases  as  occurring  after  forty  years  of 
age  (29).  After  the  menopause  a  senile  form  of  endometritis  may 
appear,  which  has  to  do  with  the  retrogressive  changes  taking  place 
at  that  time  in  the  uterus. 

The  symptoms  characteristic  of  endometritis  are  leucorrhoea  and 
menorrhagia.  The  secretion  from  the  body  of  the  uterus  is  less  viscid 
than  that  from  the  cervix,  and  may  be  clear ;  but  more  frequently  it  is 
muco-purulent.  It  may  be  tinged  with  blood  so  that  the  patient  believes 
herself  to  be  more  or  less  continually  unwell.  Sometimes  it  comes  away 
more  freely  than  at  others,  as  if  it  collected  in  the  uterus,  or  as  if  there 
were  hypersecretion  at  intervals.  It  may  be  so  irritating  as  to  excoriate 
the  vulva. 

Menorrhagia  is  generally  present,  but  not  always.  In  some  cases  the 
loss  may  be  so  considerable  as  to  suggest  malignant  disease,  and  even  to 
endanger  the  patient's  life  by  profound  anaemia. 

Of  the  exact  relation  of  these  symptoms  to  the  anatomical  changes  to 
be  immediately  described,  we  do  not  yet  know  enough  to  make  definite 
statements.  Olshausen,  who  first  described  endometritis  f ungosa,  —  a 
state  in  which  the  changes  are  interstitial,  —  drew  attention  to  haemor- 
rhage as  the  prominent  symptom  in  these  latter  cases.  Wyder  also,  who 
has  studied  the  mucous  membrane  changes  found  with  fibroid  tumours, 
maintains  that  bleeding  occurs  in  interstitial,  but  not  in  glandular 
endometritis.  On  the  other  hand,  Veit  holds  that  bleeding  may  occur 
with  either  variety.  Whatever  be  the  reason  of  the  haemorrhage,  this 
is  the  symptom  which  most  immediately  affects  the  patient's  health  and 
calls  for  prompt  treatment. 

Pain  at  tlie  menstrual  period  is  sometimes  present,  although  it  is 
less  frequent  in  endometritis  than  in  iuflammatiou  of  the  uterine  append- 


204  SYSTEM   OF  GYN.-ECOLOGY 

ages.  It  is,  of  course,  characteristic  of  the  exfoliative  form.  The  weak 
back  and  other  paius  will  be  considered  under  chronic  metritis. 

The  reproductive  function  is  liable  to  be  affected,  although  it  is  sur- 
prising how  many  patients  show  all  the  symptoms  of  endometritis  in 
the  intervals  between  conception.  Sterility  is  occasionally  found,  but  it 
is  diificult  to  say  whether  it  be  not  due  to  associated  inllammation  of  the 
uterine  appendages,  as  undoubtedly  is  the  case  in  gonorrhoeal  infection. 
Definite  information  as  to  the  effect  of  uterine  secretions  on  the  vitality 
of  the  spermatozoa  is  wanted.  Cases  in  which  conception  after  a  period 
of  sterility  follows  shortly  on  curetting,  point  to  the  fact  that  the 
diseased  mucosa  in  some  way  prevents  conception.  Abortion  is  un- 
doubtedly often  due  to  the  morbid  condition  of  the  mucous  membrane, 
which  leads  to  haemorrhages  into  it,  and  to  bad  implantation  or  death 
of  the  ovum. 

Pathology  in  Relation  to  Physical  Signs. —  Pathology  has  here  ren- 
dered service  by  explaining  the  conditions  found  by  the  sound  and 
curette,  the  two  instruments  usually  employed  in  the  recognition  of 
endometritis. 

The  only  changes  in  the  uterus  are  the  increase  in  the  size  of  its 
cavity,  and  the  swollen  and  soft  condition  of  the  mucous  membrane. 
The  latter,  moreover,  is  sometimes  thrown  into  rough  projections,  and  is 
also  so  congested  that  it  bleeds  easily.  All  of  these  features  are  recog- 
nisable by  careful  use  of  the  sound.  In  fact,  it  is  for  the  exploration  of 
the  mucosa  rather  than  for  determining  the  position  of  the  uterus,  that 
we  find  the  sound  of  service ;  it  shows  that  the  cavity  of  the  uterus  is 
always  enlarged  in  cases  of  endometritis.  Rough  granulations  can  be 
detected  by  holding  the  handle  delicately ;  and  even  the  peculiar  soft 
character  of  the  thickened  membrane  may  be  thus  recognised.  If  bleed- 
ing occurs  after  its  use,  congestion  of  the  mucosa  exists.  It  is  also  said 
that  its  introduction  is  accompanied  with  pain,  and  that  areas  painful 
to  touch  can  be  made  out  over  the  fundus  (Routh),  or  in  other  parts  of  the 
uterus  (Veit).  It  is  extremely  difficult,  however,  to  exclude  peritonitic 
or  cellulitic  conditions  which  would  also  cause  pain  from  the  movement 
given  to  the  uterus  as  the  sound  is  introduced. 

The  hypertrophied  mucosa  can  be  easily  scraped  away  by  the  ciirette, 
and  its  microscopic  examination  by  the  pathologist  has  done  much  to 
clear  up  our  conception  of  endometritis,  although  much  has  yet  to  be 
learned.  Cornil,  de  Sinety,  Ileinricius,  Kiistner,  Olshausen,  Ruge,  and 
Wyder  have  all  made  important  contributions  on  the  pathology  of  the 
changes  of  the  endometrium  in  endometritis.  Olshausen  describes 
changes  in  what  he  calls  endometritis  fungosa,  of  which  the  leading 
symptom  is  haemorrhage.  He  found  the  mucosa  hypertrophied  to  three 
or  four  times  its  normal  thickness,  and  elevated  throughout  in  a  cushion- 
like swelling,  or  in  discrete  spongy  masses.  The  change  stops  at  the 
OS  internum,  and  docs  not  affect  the  cervix.  The  portions  removed  by 
the  curette  sliow,  on  ]nic,ros(!opic  examination,  gr(!at  "  hypertr()})hy  of 
the  mucosa,  with  increase  of  all  its  elements,  moderate  dilatation  of  the 


INFLAMMATION   OF   THE    UTERUS 


uterine  glands,  enlargement  of  the  blood-vessels,  and  marked  cellular 
infiltration  of  the  connective  tissue."  The  glands  are  not  enlarged  so 
as  to  produce  cystic  dilatations. 

De  Sinety  describes  three  forms  of  vegetations  removed  by  the 
curette.  In  one  the  tissue  consists  mostly  of  dilated  blood-vessels ;  in 
another  of  dilated  hypertrophied  glands ;  in  a  third  of  embryonic 
tissue,  with  but  few  blood-vessels  and  only  traces  of  glands.  These 
three  forms  of  granulations  he  associates  with  the  three  kinds  of  dis- 
charge—  sanguineous,  leiichorrhoeal,  and  muco-purulent. 

Ruge  (29)  describes  three  forms  —  "the  glandular,  the  interstitial, 
and  the  mixed."  In  the  glandular  a  section  shows  that  the  glands, 
instead  of  running  more  or  less  straight  downwards,  are  cut  across  in 
all  directions.  Their  appearance  on  section  varies  as  the  glands  have 
changed  their  direction,  or  their  epithelium  has  been  altered,  star-like 
and  saw-like  figures  being  produced.  Sometimes  they  are  dilated  into 
cysts.  In  the  interstitial  form  the  stroma  is  filled  with  small  round  cells, 
and  the  vessels  are  dilated  and  tortuous  ;  but  the  glands  are  not  affected. 
The  mixed  form  is  a  combination  of  the  other  two.  The  glandular  occurs 
in  more  advanced  life ;  the  interstitial  at  all  periods. 

Wyder  (44)  has  studied  the  changes  in  the  mucous  membrane  in  endo- 
metritis accompanying  fibroid  tumours.  He  describes  Ruge's  glandular 
form  as  principally  accompanying  subserous  fibroids,  and  not  having 
haemorrhage  as  a  symptom.  In  the  interstitial  variety,  in  which  licsmor- 
rhage  is  prominent,  the  glands  are  constricted  at  various  points  and 
transformed  into  cysts  ;  or  they  are  compressed  and  atrophied.  As  the 
result  of  this  the  glands  are  few  in  number.  The  interglandular  tissue 
is.  marked  by  the  abundance  of  its  vessels  :  it  appears  in  parts  as  a  tissue 
rich  in  spindle  cells  with  processes  which  give  it  a  striated  appearance ; 
in  other  parts  it  is  transformed  into  a  fibrous  tissue  with  few  cells.  The 
constricted  glands  may  appear  as  clear,  transparent  vesicles,  projecting 
above  the  surface  of  the  membrane.  The  cicatrisation  of  the  connective 
tissue  compresses  the  vessels  and  leads  to  hgemorrhage.  The  process 
may  go  on  till  all  the  glands  have  disappeared,  and  the  mucous  coat  is 
represented  by  a  homogeneous  connective  tissue,  wav}^  in  outline,  which 
may  be  covered  by  a  layer  of  epithelium.  When  the  dilated  cystic  glands 
form  distinct  projections  on  the  surface  we  have  a  polypoidal  glandular 
endometritis,  which  passes  insensibly  into  mucous  polypi. 

Cornil  in  his  lectures  on  metritis  gives  a  very  complete  account 
of  the  appearance  of  the  mucous  membrane.  Its  surface  is  fungoid 
instead  of  smooth,  and  shows  villous  projections  and  cysts  the  size  of  a 
pin-head.  On  section  it  is  2  to  10  mm.  thick  —  instead  of  1  mm.  as  in 
the  normal  condition.  The  glands  are  more  tortuous;  and,  what  is  un- 
like a  non-malignant  condition,  have  grown  beyond  the  usual  limit  into 
the  muscular  wall.  The  glandular  cells,  though  chronically  inflamed, 
retain  their  cilia.  The  layer  of  flat  cells  separating  them  from  the  inter- 
glandular tissue  is  also  undisturbed,  which  is  of  importance  in  diagnosing 
it  from  epithelial  cancer.    That  it  is  a  true  inflammatory  change  is  seen 


2o6  SYSTEM   OF  GYNAECOLOGY 

from  the  excess  of  mucus,  the  multiplication  of  epithelium,  and  the 
migration  of  leucocytes.  Mucous  plugs  may  be  seen,  recalling  the  hya- 
line casts  of  albuminuria.  Karyo-kinesis  can  often  be  observed  in  the 
gland  cells.  Lymphoid  cells  are  found  in  the  gland  cavities  which  have 
escaped  from  the  capillaries  and  passed  through  the  gland  cells.  The 
interglandular  tissue  shows  dilatation  of  its  vessels  and  infiltration  with 
wandering  lymphoid  cells,  while  the  closely  packed  ovoid  cells,  of  which 
it  is  normally  composed,  swell  up  and  become  spherical. 

Heinricius  has  also  described  specimens  taken  from  cases  of  endome- 
tritis fungosa.  He  finds  the  stroma  between  the  glands  to  consist  of 
a  basis  of  stellate  corpuscles,  with  anastomosing  processes,  upon  and 
between  which  lie  two  varieties  of  cells — some  large,  oval,  and  faintly 
stained ;  others  small,  round,  and  deeply  stained.  The  former  are  the 
nuclei  of  an  endothelium,  the  latter  are  lymph  corpuscles.  His  descrip- 
tion of  the  interstitial  tissue  makes  it  consist,  then,  chiefly  of  lymph 
sinuses.  As  the  result  of  the  inflammation,  the  lymph  corpuscles  and 
those  of  the  endothelium  proliferate  and  produce  an  appearance  which 
resembles  a  small-celled  infiltration,  as  the  basis  of  the  network  is 
obscured  by  the  cells.  Thus  he  differs  from  other  observers  in  regard- 
ing the  small  cells  as  occupying  lymph  spaces. 

Relation  of  Micro-organisms  to  Endometritis.  —  We  have  already  re- 
ferred to  this  matter  in  speaking  of  the  etiology  of  uterine  inflammation ; 
but  it  is  especially  in  connection  with  the  pathology  of  the  endometrium 
that  the  subject  comes  up  for  consideration.  While  attention  is  being 
directed  more  and  more  to  the  part  played  by  micro-organisms  in  inflam- 
mation of  the  uterus,  and  too  much  stress  cannot  be  laid  on  the  germ- 
theory  in  so  far  as  it  leads  to  rigorous  antisepsis  in  practice,  the  question 
is  naturally  asked,  What  direct  proof  is  there  of  the  part  played  by 
micro-organisms  in  endometritis  ?  It  can  only  be  answered  from  obser- 
vations made  directly  on  the  endometrium. 

As  an  illustration  of  the  importance  attached  to  micro-organisms,  we 
may  take  the  most  recent  classification  of  the  varieties  of  endometritis 
given  by  Winckel,  who  arranges  them  in  two  groups,  as  they  are  due 
to  micro-organisms  or  not.  In  the  latter  group  he  places  —  i.  Simple 
catarrh  due  to  disturbance  of  circulation,  as  in  chlorosis,  uterine  displace- 
ments, faults  in  dress,  mode  of  life,  etc. :  ii.  Ilmmorrhagic  endometritis,  as 
in  acute  and  infectious  diseases :  iii.  Decidual  endometritis  after  abortion ; 
and  iv.  Exfoliative  endometritis.  In  the  former  group  he  places  —  v. 
Gonorrhf/ial  endometritis:  vi.  Tubercular  endometritis:  vii.  Puerperal 
septic  endometritis,  usually  due  to  the  streptococcus  longus,  more  rarely 
to  a  staphylococcus  or  to  the  bacterium  coli  commune :  viii.  Saprophytic 
endometritis,  due  to  combination  of  cocci  and  bacilli,  of  which  the  senile 
purulent  endom,etritis  is  probably  one  form:  ix.  The  so-called  diphtheritic 
endometritis  which  is  due  to  streptococci :  x.  Syphilitic  endometritis  —  the 
cervical  mucous  membrane  exposed  ))y  laceration  being  a  favourable 
nidus,  but  infection  of  tlie  decidua  the  mr)re  im])orta,nt  cause:  xi.  Endo- 
metritis duo.  to  fnixji,  Wia  yeast  plant  having  been  cultivated  from  the 


INFLAMMATION  OF   THE    UTERUS  207 

secretion;  and  xii.  Endometritis  due  to  arnoebai  —  protoplasmic  bodies 
with  nuclei  and  vacuoles  being  present  in  the  dilated  uterine  glands, 
and  causing  proliferation  of  epithelium. 

Such  a  classihcation  suggests  that  micro-organisms  are  very  important 
factors  in  the  changes.  At  the  same  meeting,  however,  of  the  German 
Gynaecological  Association,  Bumm  gave  the  results  of  the  direct  exami- 
nation of  the  secretions  from  forty-hve  cases  of  endometritis  in  the  living 
subject;  and  he  concludes  that  the  affection  of  the  mucous  membrane  is 
not  kept  up  by  micro-organisms,  and  that  their  presence  is  accidental, 
and  varies  with  the  character  of  the  secretions.  He  adds,  however,  that 
the  supposition  that  chronic  endometritis  has  nothing  to  do  with  micro- 
organisms is  not  incompatible  with  the  fact  that  it  may  be  the  result  of 
a  septic  or  gonorrhoeal  infection.  So  also  Gottschalk  and  Immerwahr. 
after  examining  sixty  cases  of  all  forms  of  endometritis,  found  micro- 
organisms in  the  secretions  of  only  one-half  of  them ;  and  to  these  they 
could  not  attribute  a  pathogenetic  importance,  although  catarrhal  inflam- 
mation might  be  attributed  to  their  agency. 

The  mucous  membrane  has  also  been  examined  in  portions  of  the 
uterus  removed  at  operations ;  and  I  have  already  referred  to  Winter's 
results,  which,  however,  were  not  made  specially  on  cases  of  endome- 
tritis. Menge  has  examined  the  mucous  membrane  from  seventy-three 
specimens,  including  all  forms  of  endometritis,  and  concludes  that  neither 
in  the  secretion  nor  in  the  mucous  membrane  are  micro-organisms  present, 
with  the  exception  of  the  gonococcus  and  the  bacillus  tuberculosis.  Fur- 
ther observations  upon  this  subject  must  be  waited  for  ;  but  for  the  pres- 
ent we  may  assume  that  micro-organisms  play  a  subordinate  part  in 
chronic  endometritis. 

The  observations  of  Pfannenstiel,  Doderlein,  Gonner,  and  others  on 
the  lochia  in  the  puerperium  show  the  importance  of  the  streptococcus 
in  puerperal  sepsis  ;  but  this  subject  belongs  to  obstetrics  rather  than  to 
gynaecology. 

The  diagnosis  of  endometritis  before  the  days  of  the  curette  was 
often  uncertain.  Haemorrhage  may  be  due  simply  to  congestion,  with- 
out permanent  changes  in  the  mucous  membrane ;  and  some  enlargement 
of  the  uterus  often  persists  after  delivery.  Unless  the  uterus  be  curetted, 
and  the  morbid  condition  of  the  endometrium  demonstrated,  our  treat- 
ment is  still  often  empirical.  We  may  satisfy  ourselves  that  there  is  no 
cause  outside  the  uterus  to  account  for  the  haemorrhage  or  leucorrhrea, 
and,  finding  the  uterus  enlarged,  we  may  assume  that  endometritis 
is  present.  Where  it  can  be  traced  back  distinctly  to  abortion,  diagnosis 
is  more  certain. 

Of  the  use  of  the  curette  for  diagnosis  the  following  illustrations  will 
serve :  — Figs.  48  and  49  are  sections  of  scrapings  taken  from  a  case  of 
interstitial  endometritis  —  the  endometritis  fungosa  of  Olshausen.  The 
patient  was  a  multipara  in  whom  profuse  menorrhagia  dated  from  her 
last  confinement.  She  was  curetted  on  two  occasions,  as  the  haemorrhage 
recurred  after  the  first  curetting.     Since  the  last  curetting  her  menstrual 


208 


SYSTEM  OF  GYNECOLOGY 


periods  have  been  normal  for  some  time.    The  sections  show  small-celled 
infiltration  in  the  interglandulav  tissue,  but  no  hyperplasia  of  the  glands. 


I'Ki.  Js.  Fig.  49. 

Section  of  tissue  removed  by  curette  from  a  case  of  interstitial  endometritis.  Fig-.  48  shows  the  glands 
and  interglandular  tissue  under  a  low  power ;  Fig.  49,  the  same  under  a  high  power,  to  show  the 
small-celled  infiltration. 


The  section  given  in  Fig.  50  was  taken  from  another  case  in  which 
the  endometritis  was  of  the  glandular  type.  The  patient,  a  nullipara, 
has  for  five  years  suffered  from  considerable  haemorrhages,  and  has  been 
curetted  on  different  occasions  during  this  period  without  the  benefit  seen 
in  the  former  case.  The  portions  removed  by  the  curette  on  the  last 
occasion  showed  marked  hyperplasia  of  the  glands,  with  proliferation  of 

the  glandular  epithelium,  as  is  well 
seen  in  the  portions  of  the  glands 
shown  in  Fig.  50.  Though  the  uterus 
is  enlarged  there  is  no  infiltration 
round  it;  but  from  the  proliferation 
of  epithelium  the  case  may  in  the 
end  prove  to  be  one  of  commencing 
cancer  of  the  endometrium ;  mean- 
while, therefore,  the  prognosis  must 
be  guarded. 
„,,,,,,  ,         The  curette  has  thus  come  to  be 

!•  ro.  .V). —  Section  of  the  glands  from  a  case  of  ,         i         ■      ,i  ■,•  e 

glandular  endometriti.s.     The  epithelium  is     Ot  great  Value  HI  tllC  recognition  Ot  On- 
undergoing  multiplication.   This  may  j.ass   domctritis,  and  of  tho  various  changes 

into  a  malignant  alicction.  '  '^ 

present  in  the  mucous  membrane. 
Its  use,  however,  is  primarily  for  treatment,  except  where  commenc- 
ing malignant  disease  is  suspected;  and  even  here,  where  as  a  diag- 
nostic moans  it  might  be  of  most  value,  it  often  fails  us.  The  portions 
of  tissue  removed  are  too  small  to  enable  us  to  form  a  definite  conclu- 
sion as  to  the  presence  or  absence  of  malignant  disease.  In  some 
cases  the  malignant  cells  may  Ijc  too  characteristic  for  doubt ;    but 


INFLAMMATION    OF   THE    UTERUS  209 

in  the  majority  of  cases  in  which  I  have  used  the  curette  for  this  purpose, 
the  appearance  of  the  tissue,  if  "  suspicious,"  has  not  amounted  to  a 
demonstration.  This  subject,  however,  belongs  to  the  diagnosis  of  com- 
mencing malignant  disease,  which  is  treated  elsewhere. 

Treatment.  —  The  constitutional  treatment  of  endometritis  will  be 
discussed  under  chronic  metritis.  The  local  treatment  consists  in  appli- 
cations made  to  the  uterine  mucous  membrane,  with  or  without  previous 
curetting.  Pjefore  having  recourse  to  local  applications  we  should  be 
satisfied  of  the  necessity  for  them.  As  in  the  case  of  cervical  catarrh, 
local  treatment  has  received  undue  attention.  Vaginal  injections,  ergotine, 
and  other  uterine  hiemostatics  should  always  have  a  fair  trial  in  tlie  first 
instance. 

Applications  are  made  in  the  solid  or  liquid  form ;  the  latter, 
either  by  means  of  injection  or  on  a  sound  dressed  with  cotton  wadding. 
The  technique  of  intra-uterine  medication  is  fully  described  in  the  chapter 
on  ''  Gyna3Cological  Therapeutics."  Here  we  have  to  consider  it  only  as 
applied  specially  to  endometritis.  With  regard  to  the  methods  mentioned, 
I  may  say  that  I  believe  only  in  the  latter;  the  introduction  of  the 
caustic  in  solid  form,  so  as  to  melt  inside  the  uterus,  is  too  indefinite  in 
its  action.  The  use  of  intra-uterine  injections  has  not  found  favour  in 
British  gynaecology  owing  to  the  dangers  connected  wath  them.  I  do  not, 
of  course,  refer  to  the  w^ashing  out  of  the  uterus  with  Fritsch's  catheter 
as  part  of  the  operation  of  curetting,  but  to  the  injection  of  caustics  bv 
special  syringes,  such,  for  example,  as  Braun's.  Lantos'  syringe, 
in  which  the  point  is  wrapped  in  cotton  wadding,  into  which  the  fluid 
exudes  through  holes  at  the  side,  is  a  safe  instrument;  but  it  does  not 
possess  any  decided  advantage  over  a  dressed  sound.  I  prefer  to  make 
applications  with  the  ordinary  sound  dressed  with  cotton  w^adding;  the 
only  objection  to  it  being  that  the  fluid  is  liable  to  be  squeezed  out  of  the 
wadding  as  it  is  carried  through  the  os.  This  difiiculty  can  be  got  over 
by  using  a  thin  film  of  wadding,  by  making  more  than  one  application, 
and  by  preliminary  dilatation  of  a  narrow  cervix.  It  is  always  well  to 
use  a  dry  sound  first  in  order  to  swab  away  the  mucus,  so  as  to  allow  the 
medicament  to  act.  The  applications  I  prefer  are  iodine,  iodised  phenol 
(consisting  of  40  grains  iodine  in  one  ounce  of  carbolic  acid),  and  pure 
carbolic  acid  prepared  by  liquefying  the  crj'^stals.  This  mode  of  intra- 
uterine application  has  been  recommended  by  Dr.  Playfair,  who  has 
devised  a  special  probe  for  it. 

Dr.  Atthill  advocates  the  use  of  strong  nitric  acid,  and  the  preliminary 
dilatation  of  the  cervix  so  as  to  allow  of  its  free  application.  He  uses  an 
intra-uterine  speculum  of  vulcanite  to  prevent  the  acid  from  acting  on  the 
cervical  canal.  Dr.  Barnes  has  devised  an  ointment-positor  for  intro- 
ducing ointments  or  fluids.  He  applies  the  iodide  of  mercury  ointment  by 
this  means,  or  tincture  of  iodine  on  a  sponge.  IMunde  uses  a  20  per  cent 
solution  of  chloride  of  zinc  in  the  manner  described  above ;  he  recom- 
mends also  pencils  containing  a  grs.  of  pow^dered  alum  and  of  iodoform, 
which  are  left  to  melt  in  the  uterus. 


SYSTEM  OF  GYNECOLOGY 


The  best  results  from  intra-uterine  medication  are  obtained  when  it 
is  applied  after  previous  curetting.  It  is  difficult  to  define  the  limits  of 
this  operation,  but  it  is  perfectly  safe,  and  I  have  never  seen  any  bad 
results  after  it.  For  this  very  reason  it  is  liable  to  be  abused,  and  to  be 
performed  in  cases  where  it  is  not  called  for.  The  fact  that  the  uterine 
mucosa  can  be  so  easily  removed,  and  is  so  rapidly  regenerated,  is  no 
argument  for  its  removal;  and  the  notion  of  a  substitution  of  new 
mucosa  free  from  germs,  under  aseptic  conditions  maintained  for  several 
weeks  by  the  use  of  intra-uterine  injections,  is  ingenious  but  open  to 
doubt. 

I  would  limit  the  operation  of  curetting  to  cases  in  which  there  is  a 
clear  history  of  recent  abortion,  in  which  there  is  considerable  menorrhagia 
which  has  not  yielded  to  ergotine,  or  in  which  the  sound  shows  the  cavity 
to  be  distinctly  enlarged  and  roughened  with  vegetations.  It  is  not 
called  for  in  cases  of  catarrhal  endometritis,  and  of  course  should  not  be 
performed  when  there  is  acute  or  subacute  inflammation  of  the  uterine 
adnexa.  Curetting  for  the  endometritis  of  fibroids,  and  for  the  diagnosis 
of  malignant  disease,  does  not  belong  to  the  subject  we  are  considering. 
The  mode  of  performing  the  operation  is  described  elsewhere.  After  it 
is  done  the  uterus  is  to  be  washed  out  with  a  weak  antiseptic,  and  the 
other  applications  then  made  as  mentioned  above.  Where  distinct  por- 
tions of  tissue  are  removed,  they  should  be  preserved  for  microscopic 
examination. 

Electricity  has  also  been  used  to  check  the  haemorrhage  in  endome- 
tritis. As  it  acts  simply  by  cauterisation  of  the  uterine  cavity  it  does 
not  present  any  advantages  over  curetting.  It  is  of  service,  however, 
in  the  endometritis  of  fibroid  tumours,  where,  in  certain  cases,  it  has  an 
effect  also  on  the  growth  of  the  tumour. 

C.  Chrojstio  Metritis.  — As  in  the  case  of  endometritis,  I  do  not  con- 
sider acute  metritis  deserving  of  separate  consideration;  it  appears  in 
mosttreatises  by  reason  only  of  the  artificial  division  of  affections  generally 
into  acute  and  chronic.  The  description  of  its  pathology  and  treatment 
is  taken  from  cases  of  puerperal  inflammation  which  do  not  concern  us 
here.  We  have  good  authority  for  discarding  it  as  a  separate  affection, 
when  Klob  states  that  he  has  not  met  with  a  single  case ;  Rokitansky ,  that 
the  uterine  tissue  is  scarcely  ever  affected  primarily  ;  Schroeder,  that  it  is 
extremely  rare  ;  while  Thomas  regards  it  as  but  a  complication  of  endo- 
metritis. Sir  William  Priestley's  description  of  it,  in  his  admirable  article 
in  Reynolds'  Hyutam  of  Medicine,  is  taken  from  puerperal  sepsis  ;  and  in 
the  non-pregnant  condition  he  describes  it  as  occurring  chiefly  after  opera- 
tions. The  use  of  antiseptics  in  vaginal  operations  during  the  last  twenty 
years,  since  his  article  was  written,  has  lessened  the  frequency  of  such 
oases.  In  the  Amei-ican  Sijstem  of  Gj/ruecologi/  I*almer  says  that  pure 
and  uncorny)]icated  metritis  rarely  if  ever  occurs. 

Acute  metritis  does  occur  as  an  exacerbation  of  the  clironic  condition, 
especially  in  connection  wil.h  tlio  congestion  at  tlie  menstrual  period,  yet 


INFLAMMATION   OF   THE    UTERUS 


here  the  chronic  affection  is  more  important.  We  may  note  also,  in 
passing,  the  great  rarity  of  suppuration  in  the  uterine  wall ;  most  of  the 
cases  thus  described  were  abscesses  in  the  cellular  tissue  beside  the 
uterus. 

With  regard  to  the  frequency  of  chronic  metritis  there  is  a  difference 
of  opinion ;  but  it  is  largely  a  question  of  terms.  In  the  present  state  of 
our  knowledge  we  are  disposed  to  relegate  to  chronic  metritis  all  cases 
of  chronic  uterine  inflammation  which  do  not  come  distinctly  under  the 
category  of  chronic  cervical  catarrh,  or  chronic  endometritis.  In  doing 
this  we  make  chronic  metritis  one  of  the  most  important  of  the  in- 
flammatory conditions  of  the  uterus.  It  may  be  argiied  that  our 
ignorance  of  its  pathology,  and  the  difliculty  of  exactness  in  its  diagnosis, 
are  not  a  sufficient  reason  for  making  it  include  a  large  group  of  cases  of 
chronic  invalidism  which  cannot  be  classified  under  the  better  known 
affections.  For  the  present,  however,  this  seems  the  best  course  for  us 
to  take.  Under  chronic  metritis  we  include  those  cases  which  Sir  James 
Simpson  described  under  subinvolution  (20),  a  term  which,  hoAvever  aptly, 
only  describes  the  conditions  under  which  chronic  metritis  most  fre- 
quently arises. 

Clinical  History  and  Symptoms. — ISTo  better  description  could  be 
given  of  the  general  features  of  cases  of  this  class  than  that  of  Bennet ; 
although  he  made  the  inflammatory  condition  of  the  cervix,  rather  than 
the  accompanying  condition  of  the  body  of  the  uterus,  the  important 
factor.  "To  this  class  belong  a  large  proportion  of  the  population  of 
sofa,  bath-chair,  nervous,  debilitated,  dyspeptic  females,  who  wander 
from  one  medical  man  to  another,  and  who  crowd  our  watering-places  in 
summer ;  most  of  them  are  suffering  from  chronic  uterine  inflammator}^ 
disease  unrecognised  and  untreated,  and  most  of  them  would,  if  their 
disease  were  only  discovered  and  cured,  become  amenable  to  the  resources 
of  our  art,  and  eventually  recover  their  health,  spirits,  and  powers  of 
locomotion.  It  is  a  singular  and  instructive  fact  that  amongst  the  male 
part  of  the  community  there  is  no  similar  invalid  population,  always  ill, 
unable  to  walk  or  ride,  constantly  requiring  medical  advice,  and  yet  living 
on  from  year  to  year,  neither  their  friends  nor  themselves  knowing  Avhat 
is  amiss  with  them,  beyond  the  evident  weakness,  dyspepsia,  etc."  (2). 

The  symptoms,  also,  which  Gooch  ascribes  to  the  irritable  uterus  we 
now  attribute  to  chronic  metritis.  "  To  embod}^  them  in  one  view,  let 
the  reader  fancy  to  himself  a  young  or  middle-aged  woman,  someAvhat 
reduced  in  flesh  and  health,  almost  living  on  her  sofa  for  months,  or  even 
years,  from  a  constant  pain  in  the  uterus,  Avhich  renders  her  unable  to 
sit  up  or  take  exercise;  the  uterus,  on  examination,  is  unchanged  in 
structure,  but  exquisitely  tender ;  even  in  the  recumbent  posture,  always 
in  pain,  but  subject  to  great  aggravations  more  or  less  frequent."  He 
thus  describes  exacerbations  which  are  characteristic:  —  "No  disease, 
however,  is  so  liable  to  relapse.  The  patient,  feeling  easy,  finding  her- 
self feeble,  and  sup]iosing  that  air  and  exercise  are  necessary  to  tho 
recovery  of  her  health,  rises  and  goes  about  again,  and  after  a  short 


SYSTEM   OF  GYNECOLOGY 


interval  of  caution,  tlirows  aside  her  fears,  engages  in  walks,  rides,  and 
gaietvj  or  takes  a  journey  to  the  sea  for  the  recovery  of  her  health.  This 
conduct  conmionly  occasions  a  complete  relapse,  and  the  patient  and  her 
attendant  are  again  involved  in  the  former  suffering,  apprehensions,  and 
difficulties"  (13). 

It  may  be  said  that  some  of  the  cases  described  by  Gooch  Avere 
cases  of  affections  of  the  Fallopian  tubes,  which  were  not  recognised  at 
the  time  at  which  he  wrote.  The  line  of  treatment,  however,  adopted 
and  the  improvement  under  it  shows  that  we  are  justified  in  considering 
them  as  cases  of  chronic  metritis.  Gooch's  reason  for  not  calling  the 
condition  a  chronic  inflammation  —  namely,  that  the  latter  is  a  dis- 
organising process,  while  the  irritable  uterus  shows  no  alteration  in 
structure  —  proves,  cm  the  contrary,  that  his  cases  were  just  what  we 
would  now  describe  as  chronic  metritis,  the  results  of  which  tend  to  be 
permanent. 

The  most  constant  symptom  is  pain  in  the  lower  part  of  the  abdomen 
and  in  the  loins.  Sometimes  it  is  spoken  of  as  fulness  or  weight  in  the 
pelvis,  or  bearing  down.  In  one  word,  as  Pozzi  puts  it,  tlie  patient 
knows  that  she  has  a  uterus.  The  pain  is  worst  when  she  is  going  about, 
and  relieved  when  she  lies  down.  In  this  respect  it  differs  from  the 
pain  of  cancer,  which  is  independent  of  exertion,  and  is  often  described 
as  worse  when  she  is  resting  at  night;,  probably  because  there  is  less  to 
distract  her  attention  from  it.  Whatever  increases  abdominal  pressure 
and  tends  to  move  the  sensitive  uterus  produces  pain.  Well-to-do 
patients,  who  can  take  relief  by  lying  on  the  sofa,  gradually  come  to 
spend  most  of  their  time  there. 

The  fact  that  the  pain  is  aggravated  by  movement,  and  relieved  by 
rest,  raises  the  question  whether  the  cause  of  it  be  not  sensitiveness  in 
the  attachments  of  the  uterus,  rather  than  in  the  organ  itself ;  whether  it 
be  not  an  associated  parametritis  or  perimetritis  ?  In  many  cases,  how- 
ever, we  cannot  find  evidence  of  these  affections.  If  I  were  to  draw  a 
fine  distinction  I  should  say,  that  when  pain  is  aggravated  by  movement 
of  the  uterus  —  as  maybe  demonstrated  on  bimanual  examination,  or 
the  use  of  the  sound  —  rather  than  by  simple  pressure  in  the  iliac  regions, 
the  lesion  is  chronic  metritis,  not  perimetritis.  We  cannot  always  be  sure 
that  painful  cicatrisation  in  the  broad  or  utero-sacral  ligaments  is  absent. 
The  pain  is  often  more  marked  in  the  left  iliac  region,  which  may  in- 
dicate cicatrisation  in  the  left  broad  ligament;  as  most  cases  of  chronic 
inetritis  date  from  the  puerperal  condition,  in  which  loft-sided  cellulitis  is 
more  frequent  ])ecause  of  the  great<;r  frequency  of  left-sided  lacerations 
of  the  cervix.  Pozzi  ascribes  this  pain  to  inflammation  of  the  left 
FaUopian  tube,  though  he  can  give  no  reason  Avhy  the  left  tube  should 
be  affected  rather  than  the  right.  The  pain,  moreover,  is  increased  by 
the  congestion  of  the  menstrual  period,  an  increase  which  is  ascribed  to 
the  flushing  of  the  painful  uterus  with  blood.  Sometimes,  however, 
patients  are  relieved  by  the  menstrual  flow,  as  by  a  local  depletion. 

Neuralgic  pains  are  frequent,  though  it  is  difficult  to  say  whether 


INFLAMMATION   OF   THE    UTERUS 


these  are  due  to  a  source  of  irritation  in  the  uterus,  or  to  the  general 
"  run-down  "  condition  of  the  system.  The  disturbances  of  digestion  may 
more  justly  be  regarded  as  reflex  neuroses  —  such  as  the  gastric  dis- 
turbances 01  pregnancy,  which  depend  upon  the  close  relation  between 
the  uterus  and  the  digestive  system.  The  constipation,  which  is  a  con- 
stant complaint,  results  probably  from  the  want  of  exercise ;  but  sometimes 
it  is  due  to  shrinking  from  the  pain  of  defaecation.  In  the  acute  exacerba- 
tions, indeed,  there  may  be  diarrhoea  with  tenesmus,  due  to  extension  of 
inflammation  to  the  rectum;  as  there  may  be  frequent  and  painful 
micturition  from  the  extension  of  inflammation  to  the  bladder. 

Disturbaiices  of  menstruation  are  often  given  as  symptoms  of  chronic 
metritis.  Painful  menstruation  is  certainly  one  of  them,  and  is  accounted 
for  by  the  congestion  of  a  tender  uterus.  Profuse  menstruation  should, 
however,  be  referred  to  an  accompanying  endometritis ;  though  Fritsch 
thinks  the  connective-tissue  formation  in  the  wall  affects  the  contractile 
power  of  the  uterus,  w^hich  he  considers  one  of  the  factors  which  regulate 
the  amount  of  the  menstrual  loss.  This  distinction  is  not  a  refinement, 
but  bears  on  treatment ;  for  such  cases  can  be  treated  by  curetting,  Avhich 
we  do  not  consider  to  be  applicable  to  metritis.  The  possibility  of  the 
haemorrhage  being  due  to  an  associated  salpingitis,  which  has  its  own 
appropriate  treatment,  should  also  be  borne  in  mind. 

The  disturbances  of  the  reproductive  function  (sterilit}-  and  abortion) 
are  also  to  be  accoimted  for  by  the  accompanying  endometritis. 

The  general  effect  on  the  patient's  nervous  system  is  perhaps  the 
most  important  of  all  the  consequences  of  this  malady,  and  shows  itself 
in  asthenia  and  hysteria.  It  is  extremely  difficult  to  say  how  far  these 
elements  enter  into  individual  cases,  but  an  accurate  appreciation  of  the 
proportion  between  the  general  and  the  local  factors  in  these  very  complex 
cases  is  of  the  first  importance  when  treatment  has  to  be  considered.  By 
asthenia  we  mean  the  real  loss  of  energy,  which  can  only  be  made  up  by 
such  a  line  of  treatment  as  the  Weir  Mitchell.  [See  the  section  on  ''  The 
iSTervous  System  in  Relation  to  Gynaecology."]  Hysteria,  of  which  the 
treatment  is  rather  a  mental  and  moral  regime,  is  also  an  important 
element  in  the  malady.  It  is  only  by  taking  into  account  the  condition 
of  the  central  nervous  system  that  we  can  explain  the  great  variability 
in  the  amount  and  seat  of  the  pain  in  chronic  metritis,  the  sudden  im- 
provements and  relapses,  and  those  cures  in  w^hich  the  result  bears  no 
pro})orti()u  to  the  means  employed. 

Pathology  in  Relation  to  Physical  Signs.  —  Still  less  is  known  of  the 
pathological  changes  in  chronic  metritis  than  in  endometritis  or  cervical 
catarrh.  We  have  seen  that  the  accessibility  of  the  cervix  to  microscopic 
examination  in  the  living  subject  has,  during  the  last  twenty  j^ears,  given 
precision  to  our  knowledge  of  its  pathology,  and  that  the  curette  is 
performing  a  like  service  for  the  endometrium  in  enabling  ns  to  study 
its  pathological  changes  during  life.  An  opportunity,  however,  for 
examining  tlie  condition  of  the  wall  is  only  given  in  the  rare  cases  of 
extirpation  of  the  uterus. 


214  SVSr£J/  OF  GYNECOLOGY 

Scanzoni's  classical  monograpli  on  chronic  metritis  deals  entirely  with 
the  naked-eye  characters. 

The  microscopic  changes  have  been  described  by  De  Sinety,  Fritsch, 
and  Cornil,  but  further  observations  are  needed. 

Scanzoni  describes  two  stages, — an  early  stage  in  which  the  uterus 
is  enlarged;  hypereemic,  and  soft,  and  a  later  one  in  which  it  is  indurated, 
aneemic,  and  hard.  Clinically  it  is  impossible  to  distinguish  two  such 
stages  :  sometimes  we  find  a  soft  uterus,  and  sometimes  a  firm  one  ;  but 
no  clinical  observations  have  demonstrated  that  the  one  condition  follows 
the  other  in  the  same  patient.     Scanzoni's  description  is  the  result  more 


Kk;.  51.  —  Section  of  the  uterine  tissue  in  a  case  of  chronic  metritis:  ct,  connective  tissue  round  tlie 
blood-vessels,  hv\  Is,  dilated  lymphatic  spaces;  «)/,  I,  muscular  fibre  cut  long-itudinally  ;  mf,  t, 
muscular  fibre  cut  transversely  (Do  Sinety). 

of  logical  deduction  from  what  we  know  of  pathological  changes  in  other 
organs  than  of  direct  study  of  the  uterus. 

De  Sinety  follows  Scanzoni  in  describing  two  stages.  The  first  is 
characterised  by  "  the  presence  in  great  number  of  embryonic  elements 
throughout  the  whole  thickness  of  the  muscular  wall.  These  elements 
are  met  with  specially  round  the  blood-vessels,  or  form  islands  of  variable 
dimensions  which  are  more  or  less  apart."  In  the  second  stage  he 
describes  marked  dilatation  of  the  lymphatic  spaces,  and  a  localised 
hyperplasia  of  the  connective  tissue  round  the  blood-vessels.  Fig.  51 
is  a  section  of  the  uterine  tissue  from  one  case  which  he  examined. 

Fritsch's  observations  were  made  on  uteri  which,  extirpated  for 
cancer,  also  showed  the  naked-eye  appearances  of  chronic  metritis.  He 
found  that  the  disj^osition  of  rauscuhir  fibre  and  connective  tissue  is  less 


INFLAMMATION  OF   THE    UTERUS  215 

regular  than  in  the  normal  uterus,  the  individual  muscular  bundles  being 
split  up  into  small  irregular  ones.  The  connective  tissue  is  greatly 
increased  in  amount,  and  its  bundles  show  remarkable  bulging  and 
luidulations  in  their  course.  Areas  of  normal  tissue  may  be  found  in  the 
same  uterus,  showing  that  chronic  metritis  may  occur  in  patches.  The 
blood-vessels  are  more  numerous  and  tortuous,  and  thus  in  places  pro- 
duce the  appearance  of  a  cavernous  tissue ;  their  walls  are  thickened, 
especially  in  the  middle  coat;  the  contour  of  the  vessel  is  masked  by  a 
connective  tissue  replacing  the  muscular  elements  in  the  Avail,  and  the 
lumen  of  the  vessel  is  often  diminished.  The  lymphatics  appear  as 
gaping  spaces  instead  of  narrow  clefts.  The  peritoneum  is  also  thickened. 
Fritsch  holds  that  the  multiparous  uterus  must  always  be  richer  in  con- 
nective tissue  than  the  nulliparous  ;  seeing  that  where  the  special  tissues 
are  destroyed  by  inflammation  connective  tissue  takes  their  jjlace,  and 
that  few  multipara  have  not  had  inflammation  in  the  puerperium. 

Cornil  also  describes,  in  cases  of  chronic  metritis  independent  of 
parturition,  a  new  formation  of  connective  tissue  between  the  muscular 
flbres ;  in  the  tissue  opaque  points  are  seen,  which  represent  arteries 
undergoing  atheromatous  degeneration.  Their  walls  are  thickened  by 
elastic  tissue.  There  is  no  cicatricial  contraction  of  this  connective  tissue, 
but  a  permanent  increase  in  volume. 

It  is  not  necessary  here  to  recapitulate  the  views  advanced  under  the 
head  of  pathology  in  the  works  of  other  writers  on  chronic  metritis ; 
these  opinions  resolve  themselves  into  a  discussion  of  the  meaning  of 
chronic  inflammation,  instead  of  giving  pathological  data  for  determining 
the  features  of  the  changes  in  the  uterus.  The  observations  of  De  Sinety, 
Fritsch,  and  Cornil  go  to  show  that  the  essential  change  in  chronic 
metritis  is  increase  of  connective  tissue  in  the  uterus.  It  is,  therefore, 
somewhat  analogous  to  that  which  occurs  in  fibroid  tumour,  save  that 
the  connective  tissue  formation  is  diffused  through  the  uterus  instead  of 
being  localised  in  masses. 

Thus  pathology  is  the  key  to  the  physical  signs.  The  uterus  is  enlarged 
throughout :  there  is  no  alteration  in  its  form ;  its  consistence  may  be 
either  firm  or  yielding.  This  equable  enlargement  of  the  uterus  can  be 
made  out  by  careful  bimanual  examination  and  confirmed  if  necessary  by 
the  use  of  the  sound. 

Diagnosis.  —  The  conditions  which  are  most  likely  to  be  mistaken  for 
chronic  metritis  are  enlargement  of  the  uterus  from  commencing  preg- 
nancy, small  fibroid  tumours,  and  malignant  disease. 

In  the  case  of  early  pregnancy,  amenorrhoea  and  other  symptoms 
shoidd  put  us  on  our  guard.  The  cervix  is  softened,  although  this 
softening  is  not  so  well  marked  in  a  multipara  where  the  cervix  has  been 
previously  indurated  by  chronic  inflammation  :  the  bimanual  examination 
shows  the  change  in  the  form  of  the  uterus  due  to  growth  of  the  ovum. 
In  ehronic  metritis  there  is  no  alteration  in  the  shape  of  the  uterus,  but  in 
pregnancy  there  is  a  globular  enlargement :  the  vaginal  finger  recognises 
the  anterior  wall  bulging  out  from  the  cervix  while  the  abdominal  hand 


21 6  SYSTEM   OF  GYNMCOLOGY 

feels  tlie  rounding  out  of  the  fundus,  combined  with  a  softness  which 
prevents  us  from  distinctly  defining  its  outline.  Where  resistance  of  the 
abdominal  walls  makes  the  bimanual  examination  difficult,  the  finger  may 
be  able  to  recognise  through  the  rectum  the  bulging  and  softness  of  the 
posterior  uterine  wall  in  contrast  with  the  thin  and  compressible  lower 
uterine  segment.  Pregnancy  can  be  detected  by  careful  bimanual  ex- 
amination as  early  as  the  eighth  w^eek.  Where  there  is  any  doubt,  by 
waiting  a  few  weeks  the  diagnosis  from  chronic  metritis  becomes  easy. 

Small  fibroid  tumours  closely  simulate  chronic  metritis.  The  symp- 
toms are  the  same ;  and  on  bimanual  examination  it  is  often  extremely 
difficult  to  distinguish  the  uneven  enlargement  of  a  fibroid  from  the  uni- 
form enlargement  of  chronic  metritis.  By  passing  the  sound  so  as  to  de- 
fine the  course  of  the  uterine  canal  and  the  position  of  the  fundus,  and 
then  making  a  careful  bimanual  examination  with  the  sound  in  position, 
we  are  able  to  detect  small  fibroids  of  the  anterior  or  posterior  wall.  Intra- 
uterine fibrous  polypi  can  only  be  recognised  by  dilating  the  cervix. 

While  the  diagnosis  of  chronic  metritis  from  small  fibroids  is  often 
of  little  moment,  the  diagnosis  from  early  malignant  disease  is  of  great 
consequence.  The  age  of  the  patient,  the  character  of  the  pain,  and  the 
nature  of  the  discharge,  must  all  be  taken  into  account.  Free  bleeding  is 
also  more  suggestive  of  malignant  disease,  especially  after  the  meno- 
pause ;  although  I  have  seen  patients  with  fungous  endometritis  and 
chronic  metritis  lose  a  considerable  amount  of  blood.  In  doubtful  cases 
the  cervix  should  be  dilated  so  as  to  allow  the  endometrium  to  be  care- 
fully examined  with  the  finger  or  curette. 

Treatment  rests  upon  pathology  ;  and  the  view  we  take  of  the  nature 
and  etiology  of  chronic  metritis  determines  our  treatment.  The  patho- 
logical facts,  so  far  as  we  know  them,  are  that  the  lesion  consists  in  an 
increased  formation  of  connective  tissue  in  the  uterus,  and  that  the  most 
favourable  circumstances  for  its  development  occur  during  the  puerperium. 

Sir  James  Simpson  rendered  a  great  service  by  calling  it  "sub- 
involution," thus  drawing  attention  to  the  importance  of  the  puerperal 
state  in  connection  with  its  etiology.  The  best  treatment  is  preventive ; 
and  the  removal  of  whatsoever  interferes  with  the  involution  of  the  uterus, 
is  to  be  put  in  the  forefront  in  the  treatment  of  chronic  metritis.  At- 
tention to  the  complete  emptying  of  the  uterus  after  delivery,  and  early 
removal  by  curetting  of  portions  retained  after  abortion,  are  of  the  first 
importance.  To  stimulate  the  involution  of  the  uterus  by  douching  dur- 
ing the  puerperium,  to  administer  ergot,  to  order  sufficient  rest,  and  to 
forljid  patients  to  return  too  soon  to  their  ordinary  duties,  are  measures 
of  preventive  treatment  which  cannot  be  overrated  in  importance. 

Fortunately  patients  with  chronic  metritis  are  not  often  sterile ;  and 
it  is  to  the  proper  management  of  a  subsequent  puerperium  that  we  must 
look  for  the  treatment  of  this  condition.  The  natural  cure  that  then 
takes  place  is  the  only  efficient  one. 

On  y)assing  now  from  preventive  treatment  to  the  general  treatment 
of  metritis,  we  sliall  find  that  to  describe  the  treatment  recommended  by 


INFLAMMATION   OF   THE    UTERUS  217 

the  various  writers  on  this  subject  would  be  simply  to  recapitulate  all  the 
resources  of  gynaecological  therapeutics.  Thus  is  revealed  the  impor- 
tance of  the  lesion,  inasmuch  as  all  the  means  at  our  command  have  been 
employed  in  dealing  with  it,  and  with  more  or  less  success  ;  yet  variety 
of  treatment  generally  means  ignorance  of  the  nature  of  the  disease  :  as 
our  knowledge  grows  our  treatment  is  simplified. 

The  main  object  of  local  treatment  is  to  diminish  passive  congestion 
of  the  pelvic  organs  ;  and  here  again  the  first  indication  is  rest.  Con- 
tinuous rest,  however,  is  bad,  for  it  favours  congestion  ;  daily  exercise  in 
the  open  air  is  as  necessary  as  an  hour  or  two  of  rest  on  the  sofa  in  the 
middle  of  the  day.  Tight  garments  which  compress  the  abdomen  should 
be  discarded ;  on  the  other  hand,  where  the  abdominal  muscles  are  flabby, 
a  well-adjusted  abdominal  belt  often  makes  the  patient  more  comfortable. 
Lax  abdominal  muscles  are  occasionally  associated  with  a  relaxed  vagina 
and  a  tendency  to  prolapse  :  in  such  cases  a  ring  pessary  to  support  the 
heavy  uterus  is  useful. 

To  stimulate  the  pelvic  circulation  the  hot  douche  is  invaluable.  It 
should  be  administered  freely  in  the  recumbent  posture,  and,  if  possible, 
by  a  trained  nurse.     It  is  of  little  value  unless  it  is  done  thoroughly. 

Preparations  of  ergot  also  lessen  uterine  congestion.  It  is  in  the 
puerperium  that  we  expect  the  most  permanent  benefit  from  this  drug, 
on  account  of  its  action  on  the  muscular  fibres  of  the  uterus,  promoting 
their  contractions  and  favouring  their  involution.  Ergot  is  also  useful  in 
other  circumstances,  especially  where  there  is  menorrhagia.  The  liquor 
hydrastis  canadensis  may  be  used  alternately  with  ergot,  although  it  is 
not  nearly  so  trustworthy. 

The  passive  congestion  can  also  be  relieved  by  depletion,  although 
this  is  not  used  nearly  so  much  now  as  formerly.  The  best  mode  is  by 
scarification  of  the  cervix;  but  we  would  limit  its  use  to  cases  where 
there  is  marked  cervical  hypertrophy.  A  more  practical  method  is  the 
abstraction  of  serum  from  the  tissues  by  glycerine  tampons,  which  have 
this  advantage  that  they  can  be  applied  by  a  nurse,  or  even  by  the 
patient  herself.  A  10  per  cent  solution  of  ichthyol  and  glycerine  I  have 
found  even  more  serviceable  than  simple  glycerine.  A  course  of  systematic 
douching,  combined  with  ichthyol  tampons,  in  the  hands  of  a  trained  nurse 
for  several  weeks  is,  in  my  experience,  the  most  satisfactory  local  treatment 
for  chronic  inetritis.  Where  the  parts  are  too  tender  for  the  regular 
application  of  ichthyol  tampons,  ichthyol  pessaries  are  a  useful  substitute. 

Attention  to  regular  evacuation  of  the  bowels  is  of  the  greatest  con- 
sequence not  only  for  lessening  pelvic  congestion,  but  also  for  improving 
assimilation.  The  benefit  derived  from  certain  mineral  Avaters  is  prob- 
ably due  largely  to  their  aperient  action  as  well  as  to  the  regular  mode 
of  life  prescribed  at  the  different  health  resorts. 

When  exacerbations  occur,  showing  that  the  affection  has  become 
acute  for  the  time,  we  have  recourse  to  hip-baths  or  warm  fomentations 
with  complete  rest,  and  to  morphia  suppositories  to  relieve  the  pain  and 
check  the  diarrhoea  which  are  sometimes  present.     For  the  irritability 


SyST£jV  OF  GYNECOLOGY 


of  the  bladder  tlie  hot  vaginal  douche   and  the   usual   sedatives    are 
useful. 

AVhere  cervical  catarrh  or  endometritis  are  the  prominent  features, 
these  must  be  treated  in  the  first  instance ;  and  the  treatment  directed  to 
them  will  lessen  the  chronic  metritis.  While  separating  these  various 
affections  for  the  purpose  of  studying  them,  we  must  remember  the 
intimate  relation  that  exists  between  them ;  so  intimate  is  it,  that  some 
writers  prefer  to  consider  inflammation  of  the  uterus  as  one  affection 
varying  in  its  manifestations  according  to  the  tissue  involved.  I  do  not 
accept  this  view,  inasmuch  as  it  suggests  that  there  is  an  entity  —  inflam- 
mation —  appearing  in  one  tissue  after  another.  Of  the  close  causal  con- 
nection, however,  between  inflammation  in  one  part  and  another,  there 
is  no  doubt.  Chronic  metritis  is  intimately  related  both  to  endometritis 
and  to  cervical  catarrh,  and  can  sometimes  be  treated  only  through  these. 
Thus,  after  curetting  the  uterus  for  endometritis  after  abortion,  or  after 
amputating  a  hypertrophied  cervix,  we  find  an  enlarged  uterus  becoming 
smaller,  and  the  general  condition  of  the  patient  undergoing  improvement. 

Attention  to  the  general  health  is  of  great  importance.  The  patient's 
diet  requires  careful  study,  and  we  must  have  regard  to  digestion  as  well 
as  to  appetite.  While  some  patients  require  feeding  up,  others  call  for 
a  restriction  of  food.  A  patient  may  eat  well  and  largely,  and  yet 
assimilation  may  be  defective.  When  this  is  the  case,  alcohol  is  often 
taken,  from  the  idea  that  it  aids  digestion  instead  of  retarding  it. 
Marked  improvement  in  the  patient's  general  condition  often  follows  on 
the  prescription  of  a  dietary  of  light  and  easily  digested  food,  with  a 
diminution  in  the  amount  of  stimulant.  Each  case  must,  of  course,  be 
studied  by  itself.  No  rules  can  be  laid  down  except  that  we  should  not 
let  the  condition  of  the  uterus  divert  attention  from  the  condition  of  the 
stomach. 

Change  of  air,  change  of  scene  and  occupation,  are  invaluable.  It  is 
to  their  influence  as  much  as  to  the  mineral  waters  that  the  benefit  from 
visiting  the  various  spas  is  due.  It  would  be  out  of  place  here  to 
enumerate  thein,  and  the  subject  has  become  of  such  importance  that 
special  works  on  the  subject  must  be  consulted. 

The  operative  treatmentof  chronic  metritisoccupies  a  very  subordinate 
place.  After  operations  on  the  cervix  it  has  been  noted  that  an  enlarged 
uterus  diminishes  in  size  :  this  is  specially  the  case  after  amputation  of 
the  cervix.  Although  this  is  a  very  important  result  of  the  operation,  the 
value  of  which  I  have  noted  repeatedly,  I  should  hardly  describe  it  as  a 
means  of  treating  chronic  metritis,  as  the  operation  is  only  called  for 
where  the  hypertrophy  of  the  cervix  itself  is  so  great  as  to  justify 
amputation  cm  independent  grounds.  Of  the  diminution  of  the  uterus 
after  Emmet's  operation  I  have  not  been  able  to  satisfy  myself,  although 
Emmet  and  other  American  operators  claim  this  as  one  of  its  beneficial 
results.  Of  the  igni-pimcture  of  the  cervix  advocated  by  Prochownik,  I 
liave  had  no  experience. 

A.   H.   Freeland   Baiiuour. 


INFLAMMATION   OF   THE    UTERUS  219 


REFERENCES 

1.  Atthill.  "On  Endometritis,"  Dublin  Journal  of  Medical  Science,  Jan.  1873. — 
2.  Bennet,  Henry.  Practical  Treatise  on  Inflammation,  Ulceration,  and  Induration 
of  the  Neck  of  the  Uterus.  London,  1845.  —  3.  Ibid.  A  Review  of  the  present  State  of 
Uterine  Patholof/y,  p.  11.  Loud.  185G. — 4.  Brennecke.  ''Zur  Aetiologie  der  Endo- 
metritis Fungosa,"  etc.,  Archiv  f.  Gyn.  Bd.  xx.  S.  45.5. — 5.  Bumm.  "  Ueber  die 
Aufgaben  weiterer  Forschungeu  auf  dem  Gebiete  der  puerperalen  Wundinfection," 
Archiv  f.  Gyn.  xxxiv.  S.  325. — H.  Cornil.  Le<;on  sur  l' Anatomie  puthologique  des 
Metrites,  etc.  Paris,  1889.  —  7.  Czeimpix.  "  Ueber  die  Beziehung  der  Uterusschleimhaut 
zu  derErltraiikungender  Adnexa,"  Zeits.  f.  Geb.u.  Gyn.  Bd.  xiii.  Hft.2.  —  8.  Duderlein. 
"  Ueber  Vorkommen  uud  Bedeutung  der  Micro-organismen  in  der  Lochieti  gesuiider  und 
kranker  Wocliueriuiien,"  Centralb.  f.  Gyn.  1888,  No.  23.  —  9.  Duncax,  Matthews. 
Diseases  of  Women.  Loudon,  1886. —  10.  Fischel.  "  Ein  Beitrag  zur  Histologic  der 
Erosienen  der  Portio  Vaginalis  Uteri,"  Archiv  f.  Gyn.  Bd.  xv.  S.  7().  — 11.  Fritsch. 
Die  Lageveranderun<jen  und  die  Entziindungen  der  Gebiinnutter.  Stuttgart,  1885.  — 12. 
Gunner.  Ueber  Micro-organismen  im  Secret  der  wieblichen  Genitulien  wdhrend  der 
Schwangerschaft  und  bei  puerperalen  Er/crankungen,  1S87,  S.  444.  — 13.  Gooch.  On 
some  of  the  most  important  Diseases  peculiar  to  Women,  etc.,  pp.  156,  157.  New  Syden- 
ham Society.  Lond.  1859. — 14.  Gottschalk.  Centralb.  f.  Gyn.  1S!!5,  No.  27.  — 15. 
Hart,  D.  Berry.  "  The  Pathological  Classiiication  of  liiseases  of  Women,  with  a 
Plea  for  a  Revision  of  Current  Views," -EcZui.  Obstet.  Trans,  vol.  xix.  p.  82.  —  IG. 
Heinricius.  "Ueber  die  chronische  hyperplasirende  Endometritis,"  J?-c//(i»  /.  Gyn. 
Bd.  xxviii.  S.  163. — 17.  Hofmeier.  "  Folgezustande  des  chrouischen  Cervixkatarrhs 
und  ihre  Behandlung,"  Zeilsch.  f.  Geb.  u.  Gyn.  Bd.  iv.  S.  331. — 18.  Lmmerwahr. 
Centralblatt  f.  Gyn.  1895,  No.  26.  — 19.  Klotz.  Gyncikologische  Studien  iiber  die  palho- 
logischen  Verdnderungen  der  Portio  Vaginalis  Uteri.  Wien,  1879. — 20.  Kuestner. 
Beitrdge  zur  Lehre  von  der  Endometritis.  Jena,  1883. — 21.  Lee.  Trans,  of  the  Med. - 
Chir.  Soc.  vol.  xxxiii.  p.  270.  — 22.  Menge.  Centralb.  f.  Gyn.  1895,  S.  714.  — 23. 
Olshausen.  "  Ueber  chronische  hyperplasirende  Endometritis  des  Corpus  Uteri," 
Archiv  f.  Grjndk.  Bd.  viii.  Hft.  1.  —  24.  Palmer.  The  Inflainiuatory  Affectioiis  of  the 
Uterus:  a  System  of  Gynecology ,  by  American  Authors.  Edited  by  Matthew  D.  Mann. 
Edin.  1887.  —  25.  Pfannenstiel.  "  Kasuistische  Beitrjige  zur  Aetiologie  des  Puer- 
peralfiebers,"  Centralb.  f.  Gyn.  1888,  S.  617.  —  26.  Playfair,  W.  S.  "  Intra-uterine 
Medication,"  British  Medical  Journal,  Dec.  1869,  March,  1880;  Lancet,  Jan.  and  Feb. 
1873.  —  27.  Pozzi.  Treatise  on  Gynecology,  Clinical  and  Operative,  The  New  Syden- 
ham Society  Translation,  1892.  —  28.  Priestley,  Sir  W.  O.  Inflammation  of  the  Uterus, 
A  System  of  Medicine,  edited  by  J.  Russell  Reynolds,  M.D.  vol.  v.  London,  1879. — 
29.  RuGE.  "  Zur  Aetiologie  und  Anatomie  der  Endometritis,"  Zeits.  f.  Geb.  u.  Gyn.  Bd. 
v.  S.  317.  —  30.  RuGE  and  Veit.  "Zur  Pathologic  der  Vaginalportion,"  Zeits.  f.  Geb. 
u.  Gyn.  1878,  Bd.  ii.  S.  415.  —  31.  Scanzoni.  Die  chronische  Metritis.  Wien,  1863. 
—  32.  ScHROEDER.  Charity  annalen  V .  Berlin,  1880,  S.  340. — 33.  SiMPst)X,  Sir  James. 
Diseases  of  Women,  p.  585.  Edin.  1872.  —  34.  Sinclair,  Wm.  Japp.  On  Gonorrhceal 
Infection  in  Women.  Lond.  1888.  —  35.  Sinety,  De.  Manuel  de  Gynecologic,  p.  327. 
Paris,  1879.-36.  Ibid.  Pp.  315,  351.-37.  Smith,  Tyler.  "Observations  on  the 
supposed  Frequency  of  Ulceration  of  the  Os  and  Cervix  Uteri,"  Lancet,  vol.  i.  1850,  p. 
474.  —  .38.  Spiegelbfrg.  "Die  Diagnose  des  ersten  Stadium  des  Carcinoma  Colli  Uteri," 
Archiv  f.  Gyn.  iii.  S.  233.-39.  Thomas.  Diseases  of  Women.  Edited  by  Paul  F. 
Munde'.  Londcm,  1891. — 40.  West.  On  the  Pathological  Importance  of  Ulceration  of 
(/le  Os /7/eW,  Croonian  Lectures.  London,  1854. — 41.  Ibid.  Diseases  of  Women.  London, 
1856.  —  42.  WiNCKKL.  "  Bericht  iiber  die  Verhandlungen  der  sechsten  Vcrsammlnng 
der  deutschen  Gesell.schaft  fiir  Gyniikologie,"  Centralb.  f.  Gyn.  1895,  No.  2(». — 43. 
Winter.  "  Die  Micro-organismen  im  Genitalcanal  der  .gcsunden  Frau,"  Zeitsoh.f.  Geb. 
u.  Gyn.  Bd.  xiv.  Hft.  2,  S.  443.-44.  Wyder.  Tafeln  fiir  den  gyndk.  Unterricht. 
Berlin,  1887.- 45.  Ibid.    "Die Mucosa  Uteri,  bei  Myomen,"  Archiv f.  Gyn.  xxix.  p.  1. 


A.  H.  R  B. 


SYSTEM   OF  GYNECOLOGY 


THE  NERVOUS  SYSTEM   IN   EELATION  TO  GYNAECOLOGY 

Ix  the  study  of  gynaecology  a  cardinal  factor,  wliicli  is  often  under- 
estimated and  even  altogether  overlooked,  is  the  highly  sensitive  nerv- 
ous organisation  of  the  female  sex.  The  mobility  of  the  nervous 
s^'stem,  especially  in  the  sphere  of  the  emotions,  which  distinguishes 
the  "wojuan  from  the  man,  influences  the  character  and  progress  of  all 
kinds  of  disease  in  women,  but  more  especially  diseases  of  the  repro- 
ductive organs.     This  factor  calls  for  very  careful  consideration. 

Up  to  the  time  of  puberty  there  is  little  if  any  marked  difference 
between  the  sexes,  either  in  health,  in  disease,  or  in  any  other  condition. 
Conventionally  they  are  separated ;  but  boys  and  girls  will  play  together, 
work  together,  and  associate  generally  in  perfect  equality ;  the  qualities 
which  distinguish  one  sex  from  the  other  being  either  latent  or  seen  but 
obscurely.  As  soon,  however,  as  the  great  function  of  menstruation  is 
established,  which  is  henceforth  to  influence  the  woman  during  the  whole 
period  of  her  sexual  life,  the  entire  system  undergoes  a  marked  change : 
the  asexual  child  becomes  a  woman ;  her  body  undergoes  characteristic 
modifications  fully  described  in  all  works  on  physiology  and  obstetrics ; 
and  with  them  are  to  be  observed  the  not  less  important  changes  in 
character,  and  in  the  general  development  of  the  nervous  system,  Avhich 
distinguish  the  woman  from  the  girl.  It  is  at  this  important  time  that 
the  conduct  of  the  health  of  the  groAving  girl  may  influence  for  good 
or  for  evil  the  whole  future  of  the  woman.  Judiciously  managed,  she 
may  be  so  trained  that  she  will  be  able  to  meet  successfully  the  strain 
on  her  nervous  system  during  her  future  life;  the  duties  of  a  wife 
and  mother,  the  struggle  with  domestic  anxieties  and  worries,  or  the 
sorrows  which  are  rarely  altogether  absent  from  the  lot  of  mankind. 
Injudiciously  managed,  as  is  the  case  with  so  many  at  this  important 
epoch,  all  those  things,  which  the  strong-bodied  and  healthily  minded 
woman  may  bear  with  no  permanent  bad  results,  Avill  tell  terribly  upon 
her.  She  will  have  no  stamina,  no  power  of  resistance  ;  and  she  may 
become  the  wretched,  broken-down  invalid  so  often  met  with  in  the 
present  day,  especially  in  those  ranks  of  life  in  which  the  evil  elfects 
of  unbalanced  culture,  and  the  bringing  up  of  girls  like  hothouse  plants, 
are  so  frequently  seen. 

This  bf;ing  so,  it  may  l)e  well  to  preface  what  has  to  be  said  on  the 
influence  of  tlie  nervous  system  on  gynaecology  by  a  few  words  on 
the  education  and  training  of  girls  at  and  after  the  establishment  of 
puberty.  This  is  all  the  more  necessary  since  the  higher  education  of 
women  has  taken  such  enormous  strides  of  late  years  that  it  is  now 
regularly  recognised,  and  is  almost  universal.  The  "  High  Schools  "  for 
girls  are  to  be  met  with  everywhere,  and  the  still  more  advanced  colleges 


THE   NERVOUS   SYSTEM  h\  RELATION    TO    GYNECOLOGY     221 

of  the  type  of  Girton  and  Newnham  are  rapidly  increasing  in  number, 
and  are  full  of  students.  The  old-fashioned  girls'  boarding-schools, 
with  their  perfunctory  education  and  their  elegant  accomplishments, 
are  driven  out  of  the  held ;  and  a  movement  which  at  first  was  scoffed 
and  jeered  at  has  now  gained  the  day. 

Let  me  say  at  once  that,  with  limitations  which  are  essential  because 
of  the  difference  of  sex  which  cannot  be  got  over,  the  movement  is  one 
which  seems  to  me  an  enormous  gain,  and  of  it  I  write  in  no  spirit  of 
opposition.  This  statement  is  needful,  since  there  is  an  unfortunate 
tendency  on  the  part  of  many  mistresses  of  high  schools  to  listen  to  the 
warnings  of  medical  men  with  incredulity,  and  to  accuse  them  of  narrow- 
mindedness  and  opposition,  of  which,  as  a  matter  of  fact,  the  great 
majority  of  them  are  in  no  way  guilty.  The  recognition  of  possible 
evils,  and  due  warning  against  them,  are  neither  the  one  nor  the  other. 

The  one  great  fault  of  those  who  manage  these  educational  establish- 
ments is  that  they  have  too  often  started  on  the  absolutely  untenable 
theory  that  the  sexual  factor  is  of  secondary  importance;  and  that 
there  is  little  if  any  real  distinction  between  a  girl  between  the  ages  of 
14  and  20,  and  a  boy  of  the  same  age. 

I  know  of  no  large  school  for  girls  where  the  absolute  distinction 
which  exists  between  boys  and  girls  as  regards  the  dominant  menstrual 
function  is  systematically  cared  for  and  attended  to.  The  feeling 
of  all  school  mistresses  seems  to  be  antagonistic  to  such  an  admission. 
The  contention  is  that  there  is  no  real  difference  between  an  adolescent 
man  and  woman ;  that  what  is  good  for  one  is  good  for  the  other ;  that 
the  apparent  differences  are  due  to  the  evil  customs  of  the  past,  which 
have  denied  to  women  the  ambitions  and  advantages  open  to  men,  and 
that  these  will  disappear  when  a  happier  era  is  inaugurated.  If  this  be 
so,  how  comes  it  that  while  every  physician  of  experience  sees  many 
cases  of  anaemia  and  chlorosis  in  girls,  accompanied  by  amenorrhoea  or 
menorrhagia,  headaches,  palpitations,  emaciation,  and  all  the  familiar 
accompaniments  of  break-down,  an  analogous  condition  in  a  school-boy 
is  so  rare  that  we  may  well  doubt  if  it  is  ever  seen  at  all  ? 

These  disorders  certainly  do  not  necessarily  result  from  the  work. 
The  successes  of  women  in  the  schools  have  been  so  striking  and  numer- 
ous that  their  capacity  for  intellectual  work  cannot  be  douV)ted  for  a 
moment.  On  the  other  hand,  the  male's  work  is  safeguarded  by  an 
amount  of  physical  exertion  in  the  way  of  sport  which  serves  to  keep  him 
in  health.  It  is  true  that  in  university  colleges  and  in  a  few  girls' 
schools  attention  has  been  paid  to  this  point  of  late  ;  but  in  a  perfunctory 
sort  of  way  at  the  best.  There  maj^  be  a  gymnasium,  or  some  forju  of 
games ;  but  while  at  a  boys'  school  cricket  and  football  are  compulsory 
—  to  say  nothing  of  the  natural  disposition  of  a  boy  to  athletic  pursuits  — 
at  a  girls'  school,  exercise  is  optional ;  and  if  a  pupil  tending  to  ill-health 
avoids  it,  little  or  no  attention  is  paid  to  the  matter.  Within  the  past 
Aveek  as  I  write,  I  have  been  consulted  in  the  cases  of  two  young  ladies, 
aged  respectively  14  and  16.     One  was  chlorotic,  and  her  mcn.struation 


SYSTEJI  OF  GYX.'ECOLOGY 


had  ceased  for  a  year.  On  taking  her  time-table  at  a  well-known  high 
school,  she  had  7f  hours'  work,  —  an  amount  not  in  itself,  perhaps,  exces- 
sive in  a  healthy  girl.  From  2.30  to  4  there  were  no  lessons,  and,  if  the 
weather  permitted,  she  might  if  she  liked  take  a  walk ;  but  it  was  not 
insisted  upon ;  and  as  she  was  naturally  languid  and  listless,  as  all  such 
girls  are,  she  rarely  did  so.  There  was  no  other  opportunity  for  exercise 
at  all.  The  other  girl  suffered  from  pronounced  menorrhagia,  anaemia, 
and  debility.  Her  time-table  was  also  seven  to  eight  hours,  and  she 
"  occasionally  took  a  walk."  In  neither  of  these  cases  had  the  school 
authorities  ever  inquired  into  the  state  of  an  all-important  bodily 
function,  which  in  both  was  verj^  markedly  aberrant;  j^et,  considering 
the  paramount  importance  of  such  symptoms  of  impaired  health  in  girls 
of  these  ages,  it  might  fairly  be  held  to  be  part  of  the  duty  of  those  in 
authority  in  such  schools  to  make  the  necessary  inquiries,  and  to  mod- 
ify the  course  of  study  or  mode  of  life  accordingly. 

While  it  is  questionable  whether  in  boys'  schools  the  attention  given 
to  exercise  and  athletics  may  not  be  excessive,  in  girls'  schools  it  is,  on 
the  other  hand,  not  nearly  sufficient.  And  yet  this  is  a  fault  which 
might  be  very  easily  remedied.  It  would  not  be  difficult  to  make  the 
games  of  girls'  schools  compulsory  as  they  are  in  public  schools  for  boys  ; 
there  are  many  games  admirably  adapted  for  women,  as,  for  example, 
golf,  hockey,  lawn  tennis,  rowing  where  it  is  feasible,  or,  it  may  be, 
bicycling.  Each  of  these  exercises  the  muscles  generally  without  the 
spasmodic  efforts  required  in  cricket  or  football,  which  may  be  too 
violent  for  some  girls.  The  result  when  such  games  are  freely  used 
must  be  well  known  to  all  who  have  a  knowledge  of  Avhat  a  thoroughly 
healthy  English  girl  may  be.  No  better  description  of  it  could  be  given 
than  that  contained  in  a  leading  article  in  the  Speaker,  on  what  tlie 
writer  calls  "  The  Lawn  Tennis  Girl " :  — 

Sensiljle  people  have  long  ago  agreed  to  accept  this  new  type  of  womanhood  as 
being  distinctly  admirable.  She  has  made  her  influence  felt  everywhere,  both  in 
real  life  and  in  fiction.  In  real  life  we  meet  her  in  every  country  house,  in  every 
foreign  hotel,  and  almost  in  every  London  square.  And  wherever  we  meet  her 
we  come  upon  an  excellent  example  of  the  healthy,  well-developed,  and  unsenti- 
mental girl  —  the  girl  who  does  not  think  it  necessary  to  devote  herself  to  the 
study  of  her  own  emotions,  and  who  finds  in  active  physical  exercise  an  antidote 
to  the  mr)rljid  fancies  which  are  too  apt  to  creep  into  the  mind  of  the  idle  and 
self-indulgent  (13). 

This  is  an  excellent  description  of  a  type  with  which  we  ai'e  all 
familiar,  and,  it  is  needless  to  say,  we  all  admire.  If  liigh-class  schools 
could  succeed  in  turning  out  girls  of  this  kind  in  larger  numV)ers  than 
at  present,  they  would  do  more  towards  lessening  the  nund)er  of  neu- 
rotic women  the  medical  profession  has  to  deal  with  than  the  medical 
profession  can  possibly  do  by  any  exercise  of  its  own  art. 

It  is  an  obvious  corollary  from  what  has  been  said,  that  it  is  the 
boundfn  duty  of  inislress.  parent,  and  doctor  to  insist  at  once  on  the 


THE  NERVOUS  SYSTEM  IN  RELATION   TO    GYNECOLOGY    223 

cessation  of  all  severe  study  when  any  of  the  physical  signs  of  illness,  such 
as  it  is  impossible  to  mistake,  have  shown  themselves, — as,  for  example, 
chlorosis,  amenorrhoea  or  menorrhagia,  wasting,  loss  of  appetite,  and  the 
like.  In  my  judgment  it  is  not  work  which  hurts,  but  perseverance  in 
work  after  nature  has  hung  out  its  danger-signals  —  work  in  an  unhealthy 
body,  the  attempt,  in  fact,  to  fight  nature.  Then,  indeed,  the  careless, 
prejudiced,  and  unwise  mistress  or  parent  may  well  find  out  that  the 
results  of  "over-pressure,"  the  very  existence  of  which  so  many  deny,  are 
a  stern  reality,  and  may  shatter  the  whole  future  of  the  girl. 

In  the  present  article  we  are  not  called  upon  so  much  to  consider 
the  subject  of  the  nervous  system  in  general,  as  its  special  influence  on 
our  work  as  gynaecologists.  Still,  the  important  question  naturally 
suggests  itself,  Are  morbid  nervous  states,  of  the  type  now  generally 
known  as  neurasthenic,  on  the  increase  amongst  us  ?  Or  is  their  sup- 
posed prevalence  due  to  more  careful  observation,  and  the  recognition 
of  conditions  formerly  unobserved,  and  not  referred  to  their  proper 
source  ? 

To  these  questions  it  is  not  easy  to  give  a  satisfactory  reph'',  for  no 
definite  statistics  exist  by  which  they  can  be  settled.  It  is  pretty  certain 
that  morbid  functional  neuroses  are  far  more  common  in  the  cultured 
and  educated  classes  than  in  the  comparatively  uneducated.  This 
accounts  for  the  absence  of  cases  of  advanced  neurasthenia  in  our  hospital 
wards  and  out-patient  clinics  in  England.  Such  states  are  indeed  almost 
limited  to  private  practice  among  the  upper  classes  of  society;  and  they 
may  explain,  to  a  great  extent,  the  comparative  neglect  of  such  illnesses, 
all-important  though  they  be,  by  our  clinical  teachers,  whose  material  for 
instruction  is  chiefly,  if  not  altogether,  supplied  by  hospital  patients. 
There  can  be  no  doubt  that  ciilture  and  education,  and  their  results 
in  increased  nerve  stimulation,  have  taken  enormous  strides  within  the 
last  fifty  years.  This  has  been  well  illustrated  by  Max  Xordau  in  his 
remarkable  Avork  on  Degeneration.  "1\\  1840,"'  he  says,  "there  were  in 
Europe  3000  kilometres  of  railway ;  in  1891  there  were  218,000  kilo- 
metres. The  number  of  travellers  in  1840  in  Germany,  France,  and 
England  amounted  to  2\  millions;  in  1891  it  was  614  millions.  In 
Germany  every  inhabitant  received  in  1840,  8  letters ;  in  1888,  200 
letters.  In  1840  the  post  distributed  in  France  94  millions  of  letters, 
in  England  277  millions;  in  1881,  595  and  1299  millions  respectively. 
In  Germany  in  1840,305  newspapers  were  published;  in  1891,6800; 
in  France  750  and  5782;  and  in  England  (1846)  551  and  2255.  All 
activities,  even  the  simplest,  involve  an  effort  of  the  nervous  system 
and  a  wearing  of  tissue.  In  the  last  fifty  years  the  population  of  Europe 
has  not  doubled,  whereas  the  sum  of  its  labours  has  increased  tenfold, 
in  parts  even  fiftvfold.  Every  civilised  man  furnishes  at  the  present  time 
from  five  to  twenty-five  times  as  much  work  as  was  demanded  of  him 
half  a  century  ago." 

It  is  reasonable  to  conclude  that  nervous  breakdown  and  morbid 
states  of  the  nervous  system  of  all  kinds  should  increase  pari  passv  with 


224  SYSTEM  OF  GYNECOLOGY 

the  increasing  developments  of  nerve  work  referred  to,  and  sucli  is  proba- 
bly the  case. 

It  is  indeed  likely  that  many  illnesses,  formerly  misunderstood  and 
neglected  as  being  beyond  the  power  of  the  practitioner  to  alleviate,  are 
now  referred  to  their  proper  cause,  and  correctly  diagnosed. 

This  is  the  view  taken  by  Professor  Allbutt,  who  contends  that 
neurasthenia  is  not  more  frequent  than  it  has  been  for  some  generations 
past,  but  that  it  is  better  understood.  Every  one  will  concede  the  cor- 
rectness of  his  contention  that  the  more  a  nervous  system  is  worked  the 
better  it  is  for  its  owner,  with  this  reservation,  which  he  fails  to  insist 
on,  that  this  must  be  in  a  healthy  body.  As  has  already  been  pointed  out, 
it  is  not  w^ork  that  seems  to  hurt,  but  work  plus  something  else,  such  as 
physical  frailty,  worry,  anxiety,  and  the  like ;  and  these  persisted  in  in 
spite  of  warning.  It  will  probably  be  generally  admitted  that  the  condi- 
tions of  modern  society  are  such  as  to  make  this  kind  of  addition  to  work 
of  the  nervous  system  increasingly  common.  It  is  remarkable,  moreover, 
that  this  type  of  disease  is  far  more  frequently  met  with  in  what  may  be 
called  the  centres  of  nervous  energy  and  strain.  I  have  constantly  ob- 
served that  such  cases  are  enormously  more  frequent  in  such  centres  of 
active  work  as  Glasgow,  Liverpool,  Leeds,  and  Manchester,  than  in  the 
comparatively  idle  and  fashionable  members  of  West  End  London  society. 
This  is  borne  out  by  the  returns  of  the  Registrar-General,  which  show 
that  in  the  census  year  the  death-rate  from  nervous  diseases  in  London 
was  only  about  22  per  10,000  persons  living,  while  it  runs  up  to  28-6  for 
Lancashire,  29-5  for  the  West  Hiding,  31-8  in  Leeds,  32-8  in  Blackburn, 
33-7  in  Preston,  and  34-5  in  Sheffield. 

The  reason  of  this  is  probably  complex.  Partly  it  may  be  due  to 
heredity,  since  patients  from  such  places  are  generally  the  daughters  of 
busy,  active,  pushing  business  men,  who  have  been  the  architects  of  their 
own  fortunes;  partly  it  may  be  due  to  the  fact  that  such  patients  live  in 
an  atmosphere  of  strain  and  bustle,  and  in  which  vicissitudes  of  fortune 
are  far  from  uncommon. 

Similarly  these  types  of  diseases  are  said  to  be  much  more  frequent 
in  such  new  and  very  "go  ahead"  countries  as  Australia  and  America;  so 
much  so,  that  neurasthenia  has  been  by  some  described  as  the  "American 
disease."  It  is  often  said  that  national  peculiarities  have  a  great  deal  to 
do  with  determining  the  liability  to  these  illnesses.  Thus  it  is  remarkable 
liow  comparatively  rare  in  this  country  are  the  aggravated  types  of  hy  stero- 
neiu-osis  (such  as  are  apparently  common  enough  in  France,  if  we  may 
judge  Vjy  the  writings  of  Charcot),  accompanied  by  trance,  contractures, 
and  the  like;  and  this  may  justly  be  attributed  to  the  greater  general 
excitability  of  French  women.  This  disease  is,  however,  very  unlike 
general  neurasthenia,  which  is  certainly  something  altogether  different 
from  the  so-called  liysterical  state,  and  is  by  nomeans  necessarily  —  or  even 
most  frerpiently  in  my  experience  — met  with  in  women  of  very  excitable 
temperament;  or  at  any  rate  not  in  idle  and  fanciful  women;  it  is  seen 
rather  in  women  of  more  than  average  intellect,  who  have  exhausted 


THE  NERVOUS  SYSTEM  IN  RELATION   TO    GYNECOLOGY    225 

their  nervous  systems  by  undue  strain  or  anxiety,  and  who  have  struggled 
with  the  early  symptoms  of  ''  nerve-tire,"  and  refused  to  take  note  of  the 
signs  of  impending  mischief. 

Having  said  so  inuch  as  to  prevention,  which  is  so  much  better  than 
cure,  as  regards  the  healthy  action  of  the  nervous  system  in  women,  let 
us  now  proceed  to  consider  it  in  its  morbid  action  as  we  observe  it  in  the 
study  of  gynaecology. 

Functional  neuroses  arise  easily  in  women;  they  may  assume 
tremendous  proportions,  and  their  growth  may  be  readily  fostered  and 
encouraged  until,  like  some  noxious  weed,  they  choke  all  health  of  body 
and  mind.  But  it  is  not  easy,  when  once  they  are  fully  established,  to 
trace  them  to  their  source  ;  and  unless  we  get  at  all  the  '\fontes  et  origines 
mali,"  which  may  differ  much  in  different  cases,  any  rational  system  of 
cure  is  practically  impossible. 

Broadly  speaking,  we  may  say  that  there  are  two  classes  of  cases 
with  which  we  have  chiefly  to  deal : 

1.  We  may  have  some  definite  uterine  or  pelvic  lesion,  which  may  be 
the  starting-point  of  secondary  reflex  neurotic  complications,  and  in  these 
cases  attention  is  mainly  to  be  directed  to  the  cure  of  the  originating 
local  complaint. 

2.  We  may  have  a  condition  in  which  some  local  lesion,  in  itself  of 
minor  importance,  may  be  found,  or  has  been  found.  This,  indeed,  may 
even  be  only  a  secondary  result  of  the  general  neurotic  condition  Avhich  is 
the  dominant  factor  in  the  patient's  health ;  and  the  treatment  of  it  may 
not  only  be  inadmissible  but,  injudiciously  carried  out,  may  be  intensely 
prejudicial,  and  very  gravely  increase  the  general  ill  health  from  which 
the  patieut  suffers.  As  a  further  development  of  this,  we  may  often  meet 
Avith  cases  in  Avhich  some  definite  existing  local  lesion  very  probably 
started  the  illness,  but  which  has  in  time  become  so  over-shadowed  by  its 
own  secondary  consequences  that  the  judicious  practitioner  Avill  minimise 
any  treatment  of  it  as  much  as  possible. 

The  importance  of  the  first  class  of  case  is  certainly  very  great,  and 
deserves  the  most  careful  study  on  the  part  of  the  gynaecologist. 

There  can  be  little  doubt  that  secondary  functional  disturbance  of 
remote  organs  very  commonly  originates  in  some  definite  morbid 
local  condition  of  the  uterus  or  ovaries,  the  irritation  being  conducted 
along  the  ganglionic  and  spinal  ner\"ous  system.  Every  practitioner  is 
familiar  Avith  the  influence  of  the  reproductive  system  in  producing  such 
a  disturbance  of  distant  organs  as  the  neuroses  of  pregnancy ;  not  only 
the  commonly  observed  morning  sickness,  Avhich  may  run  into  uncontrol- 
lable and  even  fatal  vomiting,  but  other  neuroses  of  an  obviously  similar 
type,  but  less  commonly  recognised,  as,  for  example,  excessive  salivation, 
cardiac  disturbances,  the  so-called  "lypothymia,"  or  partial  trance,  and 
such  AA'ell-marked  mental  conditions  as  extreme  depression  of  spirits  or 
insanity. 

It  is  familiar  to  the  obstetrician  that  in  many  of  these  cases  all  general 
treatment  fails,  while  local  treatment,  such  as  the  application  of  carbolic 

Q 


226  SYSTEM   OF  GYiV.-ECOLOGY 

acid  or  iodine  to  an  inflamed  or  abraded  cervix,  or  the  lifting  of  a 
retro  verted  gravid  uterus  out  of  the  pelvic  cavity,  may  give  relief  at 
once. 

That  similar  local  irritations  in  the  non-pregnant  woman  may  set  up 
marked  distal  disturbances  is  a  fact  which  the  general  physician  is  very 
apt  to  overlook ;  hence  many  a  sufferer  has  been  uselessly  treated  by 
incessant  drugging,  whose  symptoms  would  at  once  have  disappeared  if 
the  coexisting  uterine  or  ovarian  source  of  irritation  had  been  detected 
and  relieved. 

Of  course  it  is  imperative  that  care  should  be  taken  not  to  overlook 
any  unsuspected  source  of  illness  of  this  kind.  Should  some  obvious 
lesion  be  found  —  such,  for  example,  as  a  hyperplastic  uterus,  a  badly 
lacerated  and  everted  cervix,  profuse  uterine  or  cervical  catarrh,  swollen 
and  tender  ovaries  and  tubes,  well-marked  flexion  or  version  —  then  no 
judicious  practitioner  would  fail  to  remedy  it  by  appropriate  treatment, 
the  details  of  which  are  fully  considered  in  the  several  articles  of  this 
work.  Above  all  things,  however,  it  is  essential  that  there  should  be 
no  mistake  about  this  — that  the  lesion  we  are  treating  should  be  real,  de- 
cided, and  unmistakable,  and  that  the  local  treatment  should  be  judicious 
and  minimised  as  much  as  possible.  We  shall  presently  have  to  dwell 
more  particularly  on  the  evil  effects  which  in  nervous  and  emotional 
women  are  apt  to  follow  injudicious  and  over-frequently  repeated  local 
treatment. 

There  are  two  possible  errors  which  may  be  made  in  connection  with 
this  matter.  One  is  that  a  distinct  local  lesion,  which  is  the  originating 
cause  of  a  secondary  nervous  disturbance,  may  be  overlooked  and  not 
treated  at  all ;  and  thus  the  nervous  condition  may  be  maintained.  The 
other  is  that  exaggerated  importance  may  be  attached  to  some  local 
lesion  which  is  detected  ;  that  the  error  of  diagnosis  may  be  accompanied 
l)y  an  error  of  judgment,  and  that  much  needless  local  treatment  of 
what  maybe  called  the  "  tinkering"  kind  is  adopted:  thus  the  coexisting 
neurosis  is  aggravated.  Both  mistakes  are  serious  ones;  but  I  am  con- 
strained to  say  —  and  the  more  I  see  of  neurotic  women  the  more  convinced 
I  am  —  that  the  latter  is  much  the  more  serious  and  common  of  the  two. 
Nothing  can  be  more  deplorably  bad  for  a  nervous,  emotional  woman, 
whose  general  health  is  at  a  low  ebb,  than  to  have  her  attention  con- 
stantly directed  to  her  reproductive  organs  by  vaginal  examinations 
repeated  two  or  three  times  a  week,  pessaries  constantly  introduced  for 
"  a  slight  displacement,"  the  cervix  frequently  cauterised,  or  the  endo- 
metrium curetted,  and  the  like;  and  yet  these  are  things  one  incessantly 
sees  in  cases  in  which,  on  examination,  no  definite  reason  for  such  inter- 
ference is  found  to  exist.  No  doubt  it  is  generally  done  in  good  faith  ; 
V)ut  the  results  arc  often  disastrous,  and  I  feel  it  to  be  my  duty  to  insist 
very  emphatically  on  the  necessity  of  carefulness  in  this  direction. 

These  remarks  apply  more  especially  to  the  second  class  of  case 
referred  to,  in  which  we  are  justified  in  concluding  that  the  local  aff(!ction 
was  either  of  secondary  importance  from  the  beginning,  or  has  become  so 


THE   NERVOUS   SYSTEM  IX  RELATION'   TO    GYNECOLOGY    227 

in  consequence  of  long-existing  bad  bodily  health  and  the  supervention 
of  a  morbid  neurotic  condition. 

It  is  scarcely  consistent  with  the  limits  of  this  paper,  which  speciall}^ 
contemplates  the  discussion  of  such  neurotic  complications  as  come  under 
our  observations  as  gynaecologists,  to  enter  into  a  detailed  description 
of  the  conditions  known  of  late  years  as  "Neurasthenic";  these  will 
naturally  be  more  fully  discussed  under  this  head.  Indeed  they  are 
protean  in  character,  and  in  no  two  cases  are  the  symptoms  identical. 
This  one  might  expect,  as  the  main  element  in  the  morbid  state  we  have 
to  deal  with  is  the  unhealthy  action  of  a  subtle  and  invisible  function, 
quite  beyond  those  ready  means  of  examination  which  we  can  apply  to 
the  heart,  lungs,  or  digestive  organs,  but  which  influences  any  or  all  of 
them  nevertheless.  Hence  the  risk  of  mistaking  disturbed  action  of 
various  parts  and  viscera  —  as,  for  example,  insomnia,  headache,  spine- 
ache,  palpitations,  nausea,  loss  of  appetite,  and  a  host  of  other  condi- 
tions—  for  diseased  states  of  parts  which,  in  themselves,  may  well  be 
substantially  healthy.  Exactly  the  same  error  may  be,  and  often  is 
made  with  reference  to  apparent  disorders  of  the  reproductive  system ; 
in  these  we  may  find  cessation  or  disorder  of  menstruation,  some  increase 
of  discharges  or  secretions,  uterine  and  ovarian  pains  and  aches  of  vari- 
ous kinds ;  but  yet  no  structural  lesion  of  any  real  moment. 

One  permanent  characteristic,  however,  is  to  be  found  in  all  cases 
of  this  sort  which  merits  the  most  careful  attention,  and  is  constantly 
overlooked ;  this  is  defective  general  nutrition,  involving  as  this,  of 
course,  does,  badly  nourished  and  therefore  imperfectly  acting  nerve 
centres,  and,  as  a  consequence,  defective  action  of  all  the  viscera  sup- 
plied and  controlled  by  them. 

This  defect  is,  indeed,  the  keynote  to  the  treatment  of  a  large  number 
of  cases  of  ill  health  in  women,  which  are  often  associated  with  morbid 
conditions  referable  to  the  reproductive  organs,  but  are  quite  incurable 
until  the  general  nutrition  and  health  of  the  patient  is  placed  on  a  sat- 
isfactory basis.  A  woman  has  some  headache,  or  other  disturbance,  and 
for  this  she  is  perhaps  advised  to  rest.  Gradually  all  healthy  habits  of 
l)oily  are  dropped,  one  by  one,  until  she  hardly  leaves  her  sofa,  and  takes 
no  kind  of  exercise.  As  a  consequence  the  appetite  fails,  less  and  less 
food  is  taken,  and  progressive  emaciation  and  great  general  debility  su- 
])ervene,  witli  all  the  well-knoAvn  attendant  symptoms  of  chronic  inva- 
lidism. Or  it  may  be  that  another  type  of  defective  nutrition  shows 
itself,  attended  Avith  a  deposit  of  unwholesome  flabby  fat  in  the  subcu- 
taneous tissues  ;  and  the  patient,  while  weak,  a  poor  eater,  invalided  and 
sofa-ridden,  becomes  overburdened  with  uuAvholesome  and  useless  fat. 

These  are  precisely  the  conditions  in  Avhich  emotional  disturbances 
of  the  worst  kind  appear.  Some  injudicious  relative  or  friend  is  rarely 
lacking  in  such  a  case  who  adds  fuel  to  the  fire  by  constant  unwise 
nursing  and  unduly  sympathetic  attendance.  In  many  instances,  it  is 
to  be  feared,  the  medical  man,  at  his  wits'  end  to  do  something,  makes 
matters  worse  by  constant  visiting;  endless  talks  as  to  symptoms  :  and 


228  SYSTEM   OF  GYNECOLOGY 

incessant  prescriptions  in  -wliicli  the  inevitable  bromide,  and  similar 
harmful  drugs,  play  a  prominent  part.  It  is  a  happy  thing  for  his 
patient  if  amongst  them  narcotics  have  not  found  a  place ;  too  often 
chloral,  sulphonal,  morphia,  and  the  like  have  been  resorted  to,  until 
at  last  the  patient  may  have  insensibly  sunk  into  the  deplorable  habits 
of  a  chloral  or  morphia  taker. 

This  description,  of  course,  refers  to  the  case  of  the  confirmed 
neurasthenic  invalid  so  often  to  be  seen.  But  short  of  so  advanced  a 
type  of  neurotic  illness  the  gynaecologist  cannot  fail  to  call  to  mind 
numberless  women  on  the  down  grade,  who  were  drifting  into  some 
such  state  of  chronic  ill  health,  the  physical  path  to  which  is  defec- 
tive nutrition,  and  who  could  almost  certainly  have  been  arrested  in 
their  downAvard  course  if  the  real  cause  of  their  illness  had  been  thor- 
oughly appreciated  and  acted  upon. 

It  follows  from  what  has  been  said  that,  in  the  large  majority  of 
neurotic  cases  coming  under  our  observation  in  gynaecologic  practice, 
the  main  object  of  treatment  should  be  to  improve  the  general  nutrition, 
and  so  to  aim  at  better  general  health.  How  is  this  difficult  task  to  be 
accomplished  ?  It  is  far  easier  to  point  out  how  it  is  not  to  be  done ;  and, 
unluckily,  the  path  which  certainly  does  not  lead  to  success  is  the  one 
most  generally  followed.  It  is  certainly  useless  in  a  confirmed  case  of 
this  kind  to  attempt  to  cure  the  patient  by  way  of  the  chemist's  shop. 
Gallons  of  physic  have  generally  been  swallowed  by  her  already,  and 
the  judicious  practitioner  will  not  add  to  the  number  of  useless  or  pos- 
sibly harmful  prescriptions  which  a  patient  of  this  kind  invariably  has 
to  show.  If  the  case  be  a  comparatively  mild  one,  a  little  common  sense, 
a  quality  not  too  generally  found  in  the  regulation  of  the  treatment  of 
neurotics,  may  be  all  that  is  required.  An  endeavour  to  ascertain  and 
remove  any  more  immediate  causes,  if  such  exist,  whether  physical  or 
mental ;  the  insistence  on  a  proper  amount  and  quality  of  easily  assimi- 
lated food;  the  removal  from  unwholesome  domestic  surroundings,  which 
may  be  brought  about  by  change  of  air  and  scene,  —  these,  or  similar  pre- 
scriptions, which  vary  in  accordance  with  the  peculiarities  of  each  indi- 
vidual case,  may  suffice  to  restore  the  patient  to  health,  and  give  back 
to  her  tlie  efficient  control  of  her  nervous  system  which  she  had  lost. 

In  the  more  severe  cases,  in  which  the  symptoms  of  neurastlienia  are 
Avell  marked  and  of  long  standing,  something  more  definite  is  required 
to  give  the  y)ationt  a  fair  chance  of  recovery.  Here  that  coml)ined  at- 
tack on  defective  nuti'ition  known  of  late  years  as  the  "rest  cure,"  or 
'*  The  Weir  Mitchell"  treatment  (so  called  after  the  well-known  Ameri- 
can physician  to  whom  wo  owe  its  introduction  as  a  systematic  method 
of  treatment)  may,  in  properly  selected  cases,  prove  an  invaluable  re- 
source. Suffice  it  to  say  that,  properly  and  judiciously  carried  out  in 
wcll-selecterl  cases,  its  results  are  most  striking  and  satisfactory,  and 
hundreds  of  women  ai'C  now  going  about  well  and  strong  who  but  for 
this  would  still  1)0  the  wretched  invalids  they  formei-ly  were. 

As  the  yti'csent  writer  was  mainly  instrumental  in  introducing  this 


THE  NERVOUS  SYSTEM  IN  RELATION   TO    GYNECOLOGY    229 

method  of  treatment  into  Europe,  he  may  perhaps  be  regarded  as  unduly 
prejudiced  in  its  favour.  He  ventures,  therefore,  to  quote  the  estimate 
formed  of  it  by  the  late  lamented  American  gynsecologist,  Dr.  Goodell, 
which  was  probably  one  of  the  very  last  things  he  ever  wrote :  — 

One  of  the  grandest  discoveries  in  the  treatment  of  the  nervous  phase  of 
women's  diseases  is  the  rest  cure,  for  which  we  owe  a  large  debt  of  gratitude  to 
Weir  Mitchell.  Formerly  there  were  in  every  city,  town,  and  hamlet,  sofa- 
ridden  and  bed-ridden  women  who  were  doomed  to  helpless  invalidism  under 
the  label  of  "weak  spine,"  of  "spinal  irritation,"  of  "irritable  womb,"  or  of 
"  chronic  ovaritis."  So  countless  were  these  cases,  in  the  young  and  in  the  old, 
in  the  married  and  in  the  single,  in  the  fruitful  and  in  the  barren,  so  much 
misery  was  entailed  on  the  sufferer  and  on  her  kin,  so  many  homes  were 
blighted,  so  powerless  was  the  medical  profession  to  give  help,  that  the  pathetic 
lament  of  the  Hebrew  prophet  could  not  have  been  better  applied  than  to  this 
great  and  wide-spreading  scourge,  "Is  there  no  balm  in  Gilead  ?  Is  there  no 
physician  there  ?  Why  then  is  not  the  health  of  the  daughter  of  mj'  people 
recovered  ?"  Yet  now  I  think  mj\self  safe  in  the  assertion  that  very  few  of  these 
cases  are  incurable,  and  that  no  other  discovery  in  medicine  has  raised  so  many 
women  from  their  beds  and  restored  them  to  lives  of  active  usefulness.  It  is  the 
miracle  of  modern  therapeutics. 

It  is,  however,  essential  that  if  treatment  of  this  kind  is  to  prove 
useful  it  should  be  adopted  in  properly  chosen  cases  only,  and  that  when 
it  is  attempted  it  should  be  done  thoroughly  and  well.  Constant  failures 
arise  from  neglect  of  one  or  other  of  these  points,  especially  of  the  latter. 
There  is  much  that  is  disagreeable  about  this  treatment,  at  least  in 
appearance;  especially  the  removal  of  the  patient  from  her  usual  domestic 
surroundings,  and  her  seclusion  in  a  properly  managed  medical  home. 
This  is  naturally  disliked,  and  it  leads  to  much  expense.  Pressure  is, 
therefore,  put  on  the  medical  man,  to  which  he  is  often  weak  enough  to 
yield,  to  treat  the  case  in  what  is  called  "  a  modified  way,"  by  "  trying  a 
little  massage"  (this  being  one  of  the  remedial  agents)  at  the  patient's 
own  home,  or  in  some  other  way  to  try  to  play  "  Hamlet "  with  the 
part  of  Hamlet  left  out.  The  inevitable  consequence  is  failure  and  dis- 
appointment, a  really  good  and  valuable  method  of  treatment  is  dis- 
credited, and  the  patient's  state  is  made  worse  rather  than  better.  I 
have  seen  so  much  of  this  that  I  cannot  too  urgently  insist  on  the 
necessity  of  thoroughness  in  any  attempt  to  carry  out  this  means  of 
cure. 

An  interesting  question  in  relation  to  diseases  of  the  nervous  system 
in  gynaecology  arises  in  connection  with  insanity.  Some  have  held 
that  insanity  may  actually  depend  on  morbid  conditions  of  the  repro- 
ductive organs;  and  it  has  even  been  suggested  that  for  the  cure  of 
certain  forms  of  insanity  associated  with  pronounced  sexual  aberrations  — 
such  as  excessive  masturbation  and  erotic  manifestations  —  the  uterine 
appendages  should  be  removed  by  operation.  Of  this  alleged  connec- 
tion I  have  never  been  able  to  find  any  reliable  evidence  at  all.  Of 
course  insane  women  are  liable  to  uterine  disease  as  sane  women  are; 


SYSTEM    OF  GYNECOLOGY 


and  "R'hen  they  have  marked  disease  of  the  reproductive  organs,  of  what- 
ever tj-pe,  it  shoukl  be  appropriately  treated,  whatever  tire  condition  of 
the  mental  fiinctions.  Inasmuch  as  the  medical  staff  of  asylums  are 
rarely  expert  in  gynsecology,  it  is  likely  that  where  so  many  women  are 
congregated  together  there  may  be  found  a  considerable  amount  of 
undetected  pelvic  disease  which  should  be  made  the  subject  of  treat- 
ment. 

In  a  paper  on  this  subject  Brown  contends  that  fully  25  per 
cent  of  the  female  patients  in  asylums  in  the  United  States  suffer  from 
some  form  of  pelvic  disease.  If  this  be  true,  it  follows  that  alienist 
phj^sicians  should  not  neglect  the  study  of  gynaecology  more  than  any 
other  department  of  medicine.  But  while  this  may  be  admitted  it  does 
not  follow  that  the  one  has  any  direct  connection  with  the  other.  Un- 
happily it  has  been  very  common  to  revert  in  a  haphazard  way  to 
operative  interference,  which,  in  my  opinion,  is  unscientilic,  unnecessary, 
and  often  hurtful.  The  excessive  masturbation  and  various  erotic 
manifestations  so  common  in  certain  types  of  insanity  are,  it  cannot  be 
reasonably  doubted,  phenomena  of  central,  and  not  of  peripheral  origin;  to 
remove  the  ovaries  or  tubes  by  way  of  curing  them  seems  to  be  altogether 
unreasonable.  It  may  be  laid  down  as  an  axiom,  which  is  consistent  with 
the  mo.st  generally  received  opinion  of  the  profession,  that  no  operation 
(jf  this  kind  is  permissible  in  an  insane  patient  unless  some  structural 
lesion  exist  which  would  call  for  or  justify  the  operation  Avere  the  patient 
sane.  Of  the  uselessness  of  such  a  procedure  a  marked  example  is  given 
in  Case  IV.  of  Brown's  paper  above  referred  to. 

There  are  other  forms  of  neurotic  disease,  however,  in  which  this 
operation  has  also  been  recommended  and  performed,  in  which,  in  my 
opinion,  it  is  still  less  admissible.  Of  late  years,  unhappily,  it  has  been 
a  not  uncommon  practice  to  remove  the  uterine  appendages  in  various 
intractable  forms  of  functional  neurosis,  not  because  they  showed  any 
kind  of  structural  disease,  but  because  the  neurotic  condition  had  pre- 
viously resisted  all  ordinary  means  of  treatment.  In  a  paper  on  this 
subject,  published  in  the  thirty-third  volume  of  the  Obstetrical  Transac- 
tions, I  have  fully  discussed  this  procedure,  and  have  brought  forward 
evidence  to  show  its  utter  uselessness.  It  is  impossible  to  speak  too 
emphatically  in  condemnation  of  a  rash  and  irretrievable  experiment  of 
this  kind. 

The  only  class  of  case  in  which  such  operations  have  any  reasonable 
claim  for  consideration  are  those  of  hystero-cpilepsy,  or  other  very  severe 
forms  of  nervous  disease,  which  are  regularly  aggravated  at  the  men- 
strual periods,  and  may  therefore  be  assumed  to  be  in  some  way  connected 
with  that  function.  It  does  not  follow  that  because  such  cases  are  worse 
during  menstruation,  when  all  the  bodily  functions  are  naturally  in  a 
state  of  unsta})le  efjuilibriiiin,  that  they  depend  upon  it.  Still  the 
supposition  that  tlie  artificial  production  of  the  mcno])ause  should  have 
a  curative  effect  in  such  cases  is  a  sufficiently  reasoiud)le  hypothesis,  and 
it  is  not  surprising  that  the  operation  should  have  been  often  performed 


STERILITY 


in  such  cases.  The  records,  however,  are  not  satisfactory.  Of  the  cases 
of  this  kind  which  have  been  publislied  of  late  years,  something  like  50 
per  cent  were  complete  failures ;  and  even  in  a  well-marked  case  the 
outcome  of  experience  tends  to  show  that  operative  interference  should 
not  be  resorted  to  unless  distinct  evidence  of  coincident  structural  mis- 
chief exist. 

W.  S.  Playfair. 

REFERENCES 

1.  Allbutt,  Prof. Clifford.  "The  Nervous Diseasesof  Modern  Life,"  Contemporaiii 
Revieio,  Feb.  1895.  — 2.  Baker,  Fordyce.  "  Uterine  Diseases  as  a  Cause  of  Insanity," 
Journal  of  the  Gynsecological  hioclety  of  Boston,  Jan.  1873.  —  3.  Boldt,  H.I.  "  Cardiac 
Neurosis  in  connection  witli  Ovarian  and  Uterine  Disease,"  A>nerica?i  Journal  of  Ob- 
stetrics, vol.  xix.  —  4.  Brown,  John  Young.  "Pelvic  Disease  in  its  Relationship  to 
Insanity  in  Women,"  American  Journal  of  Obstetrics,  vol.  xxx.  —  5.  Goodell,  \V'm. 
"The  al)nse  of  Uterine  Treatment  through  mistaken  Diagnosis,"  The  Medical  News, 
Dec.  7,  18S9;  Clinical  Gyniecolof/y  by  American  Authors,  vol.  i.  —  (i.  jMuret.  "  Le 
role  dusystemenerveux  dans  les  affections  gynecologiques,"  Revue  medicnle  de  la  Suisse, 
June  188-1. — 7.  Nordau,  Max.  Degeneration  (English  translation),  AVilliara  Heine- 
mann,  1895.  —8.  Ohr,  C.  H.  "  Genital  Reflex  Neurosis  in  Females,"  American  Journal 
of  Obstetrics,  vol.  xvi.— 9.  Playfair,  W.  S.  "On  the  removal  of  the  Uterine  Ap- 
pendages in  cases  of  Functional  Neuroses,"  Obstetrical  Transactions,  vol.  xxxiii.  — 10. 
Semon,  Felix.  "  The  Sensory  Throat  Neurosis  of  the  Climacteric  Period,"  British 
Medical  Joxtrnal,  Jan.  5,  1895. — 11.  Skene.  "Gynecology  as  related  to  Insanity  in 
Women,"  Diseases  of  Women,  p.  929e<  seq.  — 12.  Store.  The  Course  and  Treatment  of 
Reflex  Insanity  in  Wo7nen.  — 13.  "The  New  Woman  and  the  Old,"  The  Speaker,  Jan. 
12,'  1895. 

w.  s.  p. 


STEKILITY 


Sterility  implies  that  condition  in  a  woman  in  consequence  of  which 
she  either  does  not  conceive,  or  if  she  conceive  is  unable  to  bear  a 
living  and  viable  child. 

Sterility  depending  on  generative  defects  in  the  male  will  not  be 
considered  here,  although  unquestionably  a  certain  percentage  of  cases 
of  sterility  in  the  woman  (variously  estimated  by  writers  on  the  subject 
as  from  7  to  15  per  cent)  depends  upon  some  such  defect  in  the 
husband.  The  cognate  subject  of  the  sterility  of  a  woman  with  one 
husband  but  not  with  another,  when  in  neither  there  appears  to  be 
any  physical  defect,  will  be  considered  under  the  heading  of  relative 
sterility.  To  apply  the  name  sterility  to  the  incapacity  to  conceive 
which  exists  before  puberty  and  after  the  menopause  appears  scarcely 
appropriate.  Sterility  under  these  circumstances  is  strictly  physiological ; 
it  is  not  governed  by  the  commencement  or  decline  of  menstruation, 
except  in  so  far  as  these  epochs  coincide  with  the  comnu^ncoment  and 
cessation  of  ovulation.     Provided  ovulation  continue,  fertility  may  pre- 


SYSTEM  OF  GYNAECOLOGY 


cede  menstruation,  exist  during  intervals  of  its  suppression,  and  beyond 
the  menopause.  But,  although  the  capacity  to  conceive  may  continue 
until  menstruation  ceases  and  even  for  some  time  afterwards,  in  the 
majority  of  women  child-bearing  terminates  some  six  or  seven  years 
prior  to  that  occurrence.  The  small  minority  in  whom  conception  occurs 
not  only  up  to  the  usual  time  of  the  menopause,  but  also  beyond  it,  is 
largely  constituted  of  healthy  women  who  have  married  late  in  life,  and 
in  whom  there  may,  consequently,  be  an  unexpended  reserve  of  fertility. 

The  statistics  given  by  writers  of  the  proportion  of  sterile  to  prolilic 
marriages  vary  much;  and  this  is  scarcely  surprising  considering  the 
wide  range  of  conditions  under  which  marriages  take  place.  Such  con- 
ditions include  the  age  at  marriage,  individual  health,  social  habits,  and 
the  customs  peculiar  to  countries  or  districts.  But  probably  the  con- 
clusion of  Matthews  Duncan,  whose  works  on  this  subject  are  classical, 
is  fairly  near  the  mark  when  he  estimates  that  in  Great  Britain  the  pro- 
portion of  one  in  ten  represents  the  number  of  sterile  marriages  ;  that 
the  most  usual  time  after  marriage  for  the  first  birth  to  occur  is  from 
twelve  to  iifteen  months,  but  that  three  years  may  be  allowed  to  elapse 
before  any  strong  presumption  of  sterility  need  be  entertained :  lastly, 
he  considers  the  most  fertile  period  of  a  woman's  life  to  extend  over 
twelve  years,  from  about  twenty-six  to  about  thirty-eight. 

Classification  of  the  Conditions  leading  to  Sterility.  —  The  most 
usual  classification  is  into  absolute  and  relative ;  another  is  into  con- 
genital and  acquired;  another  into  permanent  and  temporary.  Dr. 
M.  Duncan's  division  is  threefold.  His  first  class  he  terms  the  class  of 
absolute  sterility  ;  in  it  he  includes  all  cases  "  in  which  there  is  no  child, 
no  miscarriage,  no  abortion,  however  early  "  ;  this  class,  he  adds,  is  some- 
times called  congenital.  His  second  class  he  defines  as  including  cases 
of  •'  sterility  not  absolute  "  ;  by  which  he  implies  the  failure  to  produce 
a  viable  child  while  there  may  be  evidence  of  conception.  His  third  class 
he  calls  relative  or  acquired  sterility,  and  in  it  he  includes  cases  "  where  a 
woman  produces  one  or  even  several  living  children,  but  in  number  not 
according  to  her  conditions  of  age  and  length  of  married  life."  The  term 
relative  sterility,  however,  is  more  frequently  used  to  indicate  the  sterility 
which  a  woman  manifests  with  one  husband,  but  not  with  another,  and 
in  which,  tlu^refore,  the  faiilt  may  be  on  the  husband's  side;  or,  on  the 
other  hand,  she  may  have  been  suffering  from  some  defect  of  the  gen- 
erative system  during  the  time  of  her  earlier  marriage  which  ceases  to 
be  potent  before  her  second.  The  term  relative  sterility  would  appear 
to  be  more  appropriate  to  these  cases  than  to  those  to  which  Dr.  Duncan 
applies  it  as  the  equivalent  of  comparative  sterility.  I  venture  to  sug- 
gest the  classification  of  cases  of  stoiility  into  absolute  and  contingent, 
and  each  class  may  be  subdivided  into  congenital  and  acquired. 

Cases  of  al)Solute  sterility  will  include  all  those  in  which,  from  organic 
defect  of  the  oi-gans  concerned  in  the  formation,  transmission  to  tlie  uterus, 
or  nidation  of  the  ova,  or  in  the  access  of  the  spermatic  fluid,  conception  is 
rendered  impossible.    The  congenital  subclass  of  this  division  will  include 


STERILITY  233 


cases  of  absence  of  the  ovaries,  or  of  the  tubes  ;  of  absence  or  non- 
development  of  the  uterus,  and  of  atresia  of  the  vagina  in  which 
operation  is  impracticable. 

In  the  acquired  subclass  will  come  cases  of  a  similar  deficiency  in  the 
generative  apparatus,  but  due  to  non-congenital  causes,  or  to  surgical 
operation.  The  cases  of  contingent  sterility  are  much  more  numerous,  and 
may  also  be  divided  into  congenital  and  acquired.  The  congenital  sub- 
class will  include  cases  of  defective  or  delayed  ovulation  associated  with 
immaturity  of  the  ovaries  ;  of  certain  cases  of  imperfect  patency  of  the 
tubes ;  of  certain  cases  of  malformation  of  the  uterus,  and  especially  of 
the  cervix,  and  of  such  vaginal  obstructions  as  are  capable  of  removal. 
The  subclass  of  cases  of  acquired  origin  will  include  cases  where  patho- 
logical but  remediable  conditions  of  the  ovaries,  tubes,  uterus,  or  vagina, 
inimical  to  conception,  have  occurred  subsequently  to  birth.  In  this 
class  would  also  come  those  cases  of  so-called  relative  sterility,  to  which 
reference  has  been  made,  in  which  a  woman  does  not  conceive  with  one 
husband,  but  does  with  another.  An  extreme  case  of  relative  sterility 
would  seem  to  be  one  in  which  the  generative  organs  of  both  husband 
and  wife  are  normal.  But  obviously,  after  all,  the  explanation  of  rela- 
tive sterility  may  simply  be  that  some  abnormal  and  unrecognised  condi- 
tion of  ovary,  tube,  endometrium,  or  vagina,  present  during  one  marriage, 
may  have  been  cured,  either  by  nature  or  art,  before  the  second  is  con- 
tracted.    Considering  the  causes  of  sterility  seriatim  we  have  then 

I.  Cases  of  absolute  sterility  in  which  there  is  (A)  congenital 
organic  defect  of  an  irremediable  character. 

1.  In  Connection  luith  the  Ovaries.  —  The  ovaries  are  very  rarely  absent 
altogether.  In  such  cases  the  uterus  is  generally  imperfectly  developed 
also,  and  there  is  complete  amenorrhoea.  To  attain  a  certain  physical 
diagnosis  of  this  condition  is  scarcely  possible ;  but  an  approximative 
diagnosis  may  be  made  if  with  an  ill-developed  uterus  we  find  the 
association  of  complete  amenorrhoea,  the  absence  of  any  indication  of 
periodic  congestion,  and  of  the  special  changes  characteristic  of  puberty. 

2.  Cases  of  absence  of  the  tubes  are  occasionally  recorded;  but  they  are 
generally  associated  Avith  some  congenital  malformation  of  the  uterus,  as 
might  be  anticipated  from  their  common  origin  in  the  ducts  of  Milller. 
Sometimes  one  tube  with  its  cornu  of  the  uterus  is  absent ;  sometimes 
both.  Sometimes  one  or  both  may  be  represented  by  a  solid  cord-like 
structure.  Sometimes  with  a  normal  uterus  the  tube  is  represented  only 
by  a  short  projection  from  the  uterine  angle,  and  in  this  case  the  supposi- 
tion is  that  its  condition  is  due  to  some  necrotic  torsion  in  early  or  intra- 
uterine life.  The  diagnosis  of  these  malformations  is  ]n-obably  beyond 
our  powers ;  but  if  both  tubes  be  affected  an  absolute  sterility  must  result. 

o.  Complete  absence  of  the  uterus  is  also  a  rare  condition,  but  cases 
where  the  uterus  is  only  rudimentary  have  frequently  been  recorded. 
In  these  cases  it  is  generally  the  amenorrha?,a  which  calls  attention  to 
the  state  of  the  pelvic  organs  ;  and  on  examination  by  the  vagina,  either 
no  indication  of  uterus  is  felt  at  its  u]i])or  end,  or  there  may  only  be  a 


234  SYSTEM   OF  GYNECOLOGY 

small  projection  representing  the  cervix:  on  further  examination  by 
the  bimanual  method  and  by  the  rectum  the  uterus  may  be  found  only 
as  a  small  body  of  a  size  var3-ing  from  a  ridge  of  the  diameter  of  a 
crow-quill  to  an  organ  not  larger  than  a  bean.  In  these  cases  sterility 
is  of  course  absolute. 

4.  Congenital  atresia  of  the  vagina  leading  to  absolute  sterility  is  not 
common ;  but  many  cases  are  on  record  where,  on  account  of  the  short- 
ness of  the  pocket  which  represents  the  vagina,  and  of  the  anatomical 
difficulties  in  the  way  of  dissection  associated  with  the  position  of  the 
bladder  and  rectum,  it  is  not  possible  to  open  it  up  so  as  to  reach  the 
uterus.  iSTot  infrequently  in  these  cases  of  abortive  vagina  rectal  ex- 
amination will  detect  also  a  very  rudimentary  uterus. 

B.  In  the  second  class  of  cases  of  absolute  sterility,  which  includes 
those  of  acquired  origin,  will  come  instances  of  somewhat  similar  organic 
defects,  but  due  to  pathological  causes  which  occurred  after  birth,  or 
ensued  upon  surgical  operation. 

1.  As  regards  the  Ovaries.  —  The  destruction  of  ovarian  tissue  by 
inflammatory,  neoplastic,  or  atrophic  disease  may  be  so  complete  as  to  be 
incompatible  with  ovulation.  It  is  presumed,  of  course,  in  these  cases, 
that  both  ovaries  are  aif ected,  and  to  a  sufficient  extent  to  destroy  their 
capacity  to  ovulate.  This  result  is  not  very  uncommon  in  connection  with 
pelvic  peritonitis  of  septic  or  gonorrhoeal  origin,  or  in  connection  with 
progressive  ovarian  atrophy ;  it  is  less  common  in  connection  with  non- 
septic  ovaritis,  or  with  neoplasms  such  as  malignant,  fibroid,  or  cystic 
growths.  Occasionally  the  ovaries  are  so  completely  covered  Avith  peri- 
tonitic  or  embedded  in  parametric  exudations  that,  even  if  ovulation 
could  proceed,  the  ova  could  not  escape  from  the  follicles  and  reach  the 
tubes.  In  this  class  would  also  come  the  results  of  such  operations  as 
double  ovariotomy  for  ovarian  cystoma,  and  removal  of  the  appendices 
either  for  disease  in  themselves,  or  in  certain  cases  of  uterine  fibroid. 

2.  In  connection  ivith  the  tubes  occur  such  cases  as  their  complete 
obstruction  by  inflammatory  pelvic  exudations,  or  by  the  pressure  of 
pelvic  tumours,  or  Ijy  adhesive  sal})ingitis  or  tubal  tuberculosis. 

3.  The  removal  of  the  uterus,  either  from  fibroid  or  malignant  disease, 
or  by  Porro's  operation,  would  obviously  be  a  cause  of  absolute  acquired 
sterility. 

4.  A  similar  result  will  follow  complete  and  incurable  atresia  of  the 
vagina  by  cicatricial  obliteration,  whether  arising  from  sloughing  due  to 
a  protracted  labour,  in  connection  with  an  exanthem,  or  from  local  injury 
of  an  accidental  or  criminal  character. 

II.  (Jasks  of  coxTiNfjEXT  s'i'EitiLiTY  are  also  divisible  into  (A)  con- 
genital and  (B)  acquired. 

A.   Into  the  congenital  class  would  come 

1.  Cases  vjhere  the  ovaries  are  present  and  free  from  organic  disease, 
h)ut  immature  ;  and  where  ovulation  is  either  unduly  delayed,  or  the 
ova  secreted  are  imxierfect.  With  this  are  often  associated  impaired 
general  health  and  an  impci-fec^t  development  of  the  other  generative 


STERILITY  235 


organs.  The  uterus  is  small,  often  anteflexed,  the  external  genitals  are 
of  a  more  or  less  infantile  character,  the  general  signs  of  puberty  are 
either  absent  or  but  feebly  developed,  and  menstruation  either  does  not 
take  place  at  all,  or  occurs  irregularly  and  scantily,  and  accompanied  by 
much  ovarian  pain.  But,  contrary  to  Avliat  occurs  in  the  corresponding 
class  under  the  heading  Absolute  Sterility,  in  these  cases,  with  the 
improvement  of  the  general  health  an  improvement  may  also  occur  both 
in  the  structure  and  functions  of  the  ovaries  ;  and  Avith  the  establish- 
ment of  normal  ovulation  pregnancy  may  ensue.  The  cases  of  this  kind 
which  come  under  notice  on  account  of  sterility  are  few,  the  state  of 
health  which  accompanies  the  sterility  being  often  also  a  bar  to  marriage ; 
but  occasionally  such  cases  come  for  advice  and  treatment,  and  in  some, 
improvement  of  the  local  and  general  conditions  has  been  followed  by 
pregnancy.  In  some,  indeed,  marriage  has  proved  an  efficient  stimulant 
to  an  improved  condition  of  ovaries ;  menstruation  and  ovulation  have 
become  healthily  established,  and  pregnancy  has  followed.  In  a  certain 
number  of  women,  however,  there  is  also  irregular,  often  painful,  and 
sometimes  delayed  menstruation  ;  but  instead  of  being  associated  with  a 
general  appearance  of  immaturity,  and  more  or  less  ill-health,  the  physical 
development  and  the  general  health  may  both  be  good,  and  the  irregular 
menstruation  and  associated  dysmenorrhoea  be  their  only  troubles.  In 
many  of  these  cases  some  affection  of  the  uterus,  such  as  a  displacement 
or  an  endometritis,  may  be  found  on  examination  ;  but,  whether  this  be  so 
or  not,  the  delayed  and  irregular  menstruation  need  of  itself  be  no  bar 
to  marriage :  marriage  indeed,  as  in  the  previous  case,  is  often  followed 
by  an  improvement  in  the  functions  of  the  ovaries  and  occasionally  by 
pregnancy. 

2.  Sterility  depending  upon  some  congenital  interference  of  a  temporary 
kind  icith  thejMtency  of  the  tubes  is  probably  uncommon ;  but  in  some  cases 
cysts  are  found  in  the  neighbourhood  of  the  fimbriated  ends  of  the  tubes 
which  might  subsequently  rupture  and  disappear,  but  which,  if  they 
remained,  would  more  or  less  interfere  with  the  entrance  of  ova.  Or  the 
occurrence  of  some  adhesion  in  the  coiirse  of  the  tubes,  due  to  a  transient 
salpingitis  which  had  disappeared  with  the  progress  of  development,  or 
to  some  torsion  of  the  tube  on  its  axis  rectified  by  casual  changes  in  the 
relative  position  of  the  pelvis  viscera,  may  likewise  be  causes  of  con- 
tingent sterility.  Diagnosis  of  these  conditions  Avould  rarely  be  practi- 
cable, and  they  lie  beyond  the  range  of  any  treatment  except  perhaps  an 
empirical  catheterisation  of  the  tubes,  a  proceeding  Avhich  can  hardly  yet 
be  spoken  of  as  always  safe  or  even  possible. 

3.  Sterility  depending  upon  congenitcd  mcdformcitions  of  the  uterus 
capable  of  treatment  is  chiefly  associated  with  those  which  involve  the 
cervix.  One  such  malformation  is  an  undue  elongation  of  the  cervix, 
which  is  often  of  a  conical  outline,  and  projects  into  the  vagina  to  the 
extent  of  an  inch  and  a  half  or  even  two  inches.  The  os  uteri  in  these 
vases  is  generally  minute  in  size,  round  or  "pin-hole"  in  form,  and  is 
often  placed,  not  centrally  at  tlu'  (MuI  of  the  cervix,  biit  rather  on  one 


236  SVSTEA/   OF  GYNECOLOGY 

side.  In  a  less  frequent  number  of  cases  a  minute  os  uteri  is  found 
associated  with,  a  sliort  and  rounded  cervix.  There  are  also  congenital 
cases  of  greater  or  less  stenosis  of  the  cervical  canal  Avithout  any  very 
marked  malformation  of  the  cervix,  the  stenosis  being  more  frequently 
at  the  site  of  the  outer  os,  less  frequently  at  the  inner  os ;  in  this  latter 
case  it  is  generally  associated  with  anteflexion  of  the  uterus.  Occasionally 
there  is  narrowing  both  at  the  external  and  internal  os,  the  intermediate 
canal  being  of  average  size ;  and  sometimes,  but  most  rarely  of  all,  there 
is  a  distinct  constriction  in  the  canal  itself.  The  relation  of  stenosis  of 
the  cervix  to  the  production  of  dysmenorrhoea  is  a  much-debated  sub- 
ject, and  need  not  be  entered  upon  here ;  but  of  its  influence  as  a  factor 
in  the  production  of  sterility  I  have  no  doubt.  The  accumulated  clinical 
evidence  in  favour  of  the  view  that  the  removal  of  stenosis  facilitates 
impregnation  is,  I  believe,  decisive.  I  have  known  some  cases  in  which 
a  single  dilatation  after  an  unfruitful  marriage  of  many  years'  duration, 
varying  from  five  to  fifteen,  has  been  followed  by  pregnancy ;  and  a  con- 
siderable number  in  which  a  series  of  dilatations,  as  may  be  required  by 
the  conditions  of  the  case,  has  been  followed  by  a  similar  result.  Such 
cases  are  also  recorded  by  Duncan.  Yet,  of  course,  this  result  may  not 
follow  even  after  complete  dilatation  has  been  accomplished ;  the  strong 
probability  in  such  cases  is  that  some  other  pathological  factor,  besides 
the  cervical  stenosis,  is  present.  But  even  if  this  be  so,  the  removal  of 
the  stenosis  is  a  useful  as  Avell  as  a  logical  proceeding,  as  it  assists  in  the 
cure  of  any  other  conditions  present  which  may  be  antagonistic  to  im- 
pregnation. For  instance,  the  cervical  stenosis  may  have  led  to  dysmenor- 
rhoea, or  it  may  be  associated  sequentially  with  some  congestive  condition 
of  uterus,  tube,  or  ovary,  either  of  which  disorder  in  its  turn  may  be  a 
cause  of  sterility.  With  the  relief  of  the  dysmenorrhoea  this  sequence  of 
congestions  may  siibside,  and  as  a  result  the  influences  hostile  to  concep- 
tion may  disappear.  On  the  other  hand,  the  endometritis  or  salpingitis  or 
ovaritis,  of  which  the  narrowed  cervical  canal  was  the  primary  cause, 
may  have  been  of  such  long  standing,  and  accompanied  by  so  much  tissue 
change,  that  even  after  the  cervical  canal  has  become  normal,  it  may 
be  difficult  or  impossible  to  bring  about  a  sufficiently  healthy  condition 
in  the  uterus  or  in  the  ovaries  to  permit  conception. 

A  hypertrophic  elongation  of  the  cervix  is  an  occasional  congenital 
defect ;  and,  as  it  simulates  prolapsus  uteri,  it  is  sometimes  called  infra- 
vaginal  prolapse.  In  these  cases  the  cervix  is  sometimes  so  unduly 
elongated  as  to  reach  down  to,  or  even  to  pass  beyond  the  vaginal  orifice, 
and  thus  to  give  rise  at  first  sight  to  the  impression  that  the  c;ise  is  one 
of  ordinary  pi'olapse.  Sometimes  this  condition  has  not  been  noticed 
before  marriage,  as  it  causes  little  or  no  inconvenience,  unless  it  be  some 
sense  of  bearing  down,  and  some  dysmenorrhoea.  But  after  marriage  it 
Vjecomes  a  source  of  marital  inconvenience,  and  the  surface  becomes 
inflamed  and  possibly  excoriated.  That  it  is  not  an  ordinary  prolapse 
is  proved  by  the  use  of  the  sound;  and  by  the  nornud  position  of  the 
body  of  the  uterus  in  the  pelvis,  as  shown  by  Ijimaiiiial  examii)atioii.     Its 


STERILITY  237 


removal  by  amputation  removes  both  tlie  dyspareunia  and  a  cause  of 
probable  sterility.  Fertilisation  in  these  cases  is  perhaps  not  impossible, 
but  I  have  seen  several  such  cases,  and  in  none  did  impregnation  take 
place  prior  to  the  removal  of  the  elongated  cervix. 

4.  Cases  of  contingent  sterility  of  congenital  origin  include  malfor- 
mations of  the  vagina  and  of  its  vulval  entrance. 

An  imperforate  hymen  is  at  once  a  barrier  to  intercourse  and  to 
conception.  A  cribriform  hymen,  or  an  unusually  thickened  annular  or 
crescentic  hymen,  may  also  render  intercourse  difficult,  and  so  may  im- 
pede the  occurrence  of  conception ;  but  it  would  not  necessarily  lead  to 
sterility.  Occasionally,  also,  we  meet  with  cases  in  which  a  transverse 
septum  exists  a  third  or  a  half  way  up  the  vaginal  canal.  Such  a 
septum,  if  imperforate,  might  permit  intercourse,  but  would  obviously 
prevent  conception ;  yet  if  an  opening  were  present  in  it,  permitting 
the  exit  of  the  menstrual  secretion,  conception  would  be  at  least  possible, 
although  if  the  opening  were  a  minute  one  it  would  not  be  probable. 
These  diaphragms  probably  arise  from  some  limited  adhesive  inflamma- 
tion of  the  vaginal  walls  in  very  early  life ;  and  there  are  grounds  for 
supposing  that  imperforate  hymen  itself  is  due  to  adhesive  inflamma- 
tion, in  early  or  even  in  intra-uterine  life,  uniting  the  free  edges  of  an 
annular  hymen.  In  both  cases  the  division  of  the  hymen  or  the  division 
of  the  septum  is  necessary.  Occasionally  the  vagina  terminates  in  a 
(■ul-de-sac,  and  between  this  and  the  uterus  a  greater  or  less  thickness 
of  cellular  tissue  is  interposed,  with  the  bladder  in  front  and  the  rectum 
behind.  In  many  of  tliese  cases,  as  stated  under  the  heading  of 
absolute  congenital  sterility,  to  dissect  through  this  tissue  to  the  uterus 
has,  for  the  reasons  there  given,  proved  difficult  or  impossible  :  in  some 
cases,  however,  the  dissection  has  been  attempted  with  success ;  and 
if  the  uterus,  tubes,  and  ovaries  be  healthy,  conception  becomes  possible. 
Sometimes  that  rare  condition,  a  double  vagina,  may  be  a  cause  of 
sterility.  If  associated  with  a  double  uterus  and  bifid  cervix,  with  one 
cervix  projecting  into  each  vagina,  the  sterility  may  arise  rather  from 
the  imperfect  character  of  the  uterus  and  of  the  cervix,  the  two  halves  of 
which  are  often  abnormally  developed,  than  from  the  divided  vagina 
being  a  barrier  to  intercourse.  One  cervix  may  be  quite  short  and 
rudimentary,  while  the  other  is  of  average  size ;  and  in  one  or  both  the 
OS  is  apt  to  be  situated  laterally,  and  to  be  very  minute  or  of  an 
irregular  outline. 

Cases  are  also  met  with  in  which  the  two  vaginas  are  so  narrow  as  to 
make  sterility  probable,  by  preventing  effective  intercourse  ;  a  difficulty 
to  be  removed  by  the  division  of  the  intervening  septum  so  as  to  throw 
the  two  into  one.  In  such  a  case,  if  the  uterus  and  organs  beyond  be- 
normal,  there  is  no  further  barrier  to  conception  ;  but  more  commonly 
the  uterus  shares  in  the  malformation.  Occasionally  one  vagina  is  of 
average  size  and  the  other  much  smaller.  Vaginismus  may  possibly  be 
a  congenital  cause  of  contingent  sterility  ;  but  as  it  is  more  frequently 
of  acqiiired  origin  it  will  be  considered  further  on. 


238  SYSTEM   OF  GYNAECOLOGY 

B.   Acquired  Contingent  Sterility. 

1.  From  Ahnormal  Conditions  of  the  Ovaries.  —  The  ovaries  maybe  so 
damaged  by  acute  or  chronic  ovaritis  that  for  a  time  the  Graafian  follicles 
do  not  mature  normally,  and  ovulation  is  either  performed  imperfectly 
or  not  at  all.  But  in  the  cases  belonging  to  this  class  the  damage  is 
not  irretrievable.  With  a  return  to  a  healthy  condition  of  the  ovary,  its 
function  is  restored  and  the  possibility  of  conception  returns.  Subacute 
ovaritis  may  arise  from  the  lesser  attacks  of  septic  or  gonorrhoeal  in- 
fection, from  limited  congestive  haemorrhage  into  the  structure  of  the 
ovaries,  from  a  chill  during  menstruation,  or  in  association  with  endo- 
metritis and  backward  displacements  of  the  uterus.  It  will  of  course 
be  understood,  as  in  the  other  classes  of  cases  in  which  the  condition  of 
the  ovaries  is  the  cause  of  sterility,  that  sterility  only  occurs  when  both 
ovaries  are  affected.  But  from  many  of  the  causes  just  enumerated 
both  ovaries  do  become  involved,  though  often  one  more  markedly 
than  the  other ;  not  infrequently  after  an  attack  of  double  ovaritis,  one 
ovary,  usually  the  right,  will  apparently  recover  completely,  so  far, 
at  least,  as  can  be  judged  by  examination,  while  the  other  remains 
tender,  swollen,  and  possibly  displaced.  And  in  many  of  these  cases 
there  is  sterility,  although  apparently  one  ovary  is  healthy.  The 
probability  in  such  cases  is  that  recovery  is  incomplete,  and  that  the 
inflammatory  attack,  to  which  one  ovary  has  succumbed,  has  also 
brought  about  some  change  in  the  structure  of  the  other  which  cannot 
be  estimated  by  a  bimanual  or  other  examination.  Possibly  also  func- 
tional disturbance  in  one  may  be  sympathetic  Avith  structural  change 
in  the  other.  In  addition  to  ovaritis  other  affections  of  the  ovaries 
have  been  referred  to  under  the  head  of  absolute  sterility  which,  if 
less  serious  in  extent  and  character,  may  be  only  temporary  causes  of 
sterility.  Such  would  be  cases  of  pelvic  peritonitis  in  which  peritonitic 
exudation,  instead  of  forming  an  impenetrable  investment  to  the  ovary, 
is  slighter  in  character,  and  after  a  time  becomes  sufficiently  thin  to 
yield  to  the  distension  of  a  maturing  Graafian  follicle,  and  to  permit  the 
ovule  to  pass  through  and  reach  the  tube.  Or  a  parametric  exudation, 
which  has  pressed  upon  and  covered  up  one  or  both  ovaries  for  a  time, 
may  be  so  absorbed  as  to  permit  their  function  to  be  restored ;  or  possibly 
oven  cystic  disease  may  be  present,  but  to  so  limited  an  extent  that 
liealthy  tissue  sufficient  for  ovulation  remains.  Temporary  malposition 
of  the  ovaries,  the  result  of  an  ovaritis  which  has  led  to  enlargement  and 
increased  weight,  and  so  to  more  or  less  prolapse,  or  the  downward 
displacement  of  both  ovaries  which  often  accompanies  retroversion  and 
retroflexion  of  the  uterus,  may  be  a  cause  of  difficulty  in  the  way  of  the 
ova  reaching  the  tube,  and  so  lead  to  a  temporary  sterility.  And,  lastly, 
apart  from  tissue-changes  and  displacements,  tlie  ovaries  may  share  in 
a  general  condition  of  depressed  innervation,  and  perform  their  function 
as  iniperf(!ctly  as  do  other  organs  of  the  body  under  similar  conditions 
of  general  health,  whether  these  conditions  l)e  associated  with  anajmia 
or  plflhora,  or  some  more  serious  morbid  diathesis.     Their  innervation 


STERILITY  239 


and  blood-supply  being  faulty,  the  ova  they  secrete  will  be  faulty  too ; 
and  sterility  will  continue  until,  with  improved  health,  their  condition,  in 
common  with  that  of  other  organs  of  the  body,  becomes  normal  and  their 
function  is  normally  performed. 

2.  The  pathological  conditions  of  the  tabes  which  lead,  while  they 
continue,  to  sterility,  would  include  the  sligliter  forms  of  double  saljnngitis, 
generally  of  septic  or  gonorrhoeal  origin,  which  terminate  without 
rendering  the  tubes  impermeable,  whether  by  internal  adhesions  or  by 
distension  with  serous,  sanguineous,  or  purulent  collections.  Mechanical 
interference  with  the  tubes  by  pressure  from  some  pelvic  tumour  would 
cease  as  a  cause  of  sterility ;  either  by  removal  of  the  latter  (were  it 
undertaken  for  any  reason),  or  by  some  such  shifting  of  its  posi- 
tion as  might  occur  with  either  a  pediculated  fibroid  or  an  ovarian 
cyst. 

3.  But  much  more  frequent  and  so  more  important  than  any  affections 
of  the  tubes  in  leading  to  contingent  sterility  are  certain,  diseases  of  the 
uterus.  And  chief  among  these  are  endocervicitis,endometritis,a,Tid  metritis. 
The  influence  of  a  severe  and  established  endocervicitis  in  favouring  steril- 
ity is  well  marked.  The  swollen  and  abraded  lining  membrane  and  the 
tenacious  muco-purulent  discharges  offer  together  a  distinct  obstruction 
to  the  ingress  of  spermatozoa,  while  the  character  of  tlie  inflammatory 
discharges  is  prejudicial  to  their  life.  The  word  obstruction  is  used  here 
in  its  widest  sense;  it  is  not  limited  simply  to  mechanical  obstruction, 
but  includes  whatever  obstacles  may  be  offered  by  the  hyperaemic  con- 
dition of  the  tissues  of  the  cervix  to  that  physiological  dilatation  of  the 
canal  which  favours  the  ascent  of  the  spermatozoa  into  the  uterine  cavity. 
That  the  obstructive  influence  of  endocervicitis  is  not  simply  hypothetical 
is  supported  by  extended  clinical  evidence  and  the  observations  of 
numerous  authors.  Eepeatedly  on  the  cure  of  endocervicitis  pregnancy 
has  ensued  in  a  patient  previously  sterile.  With  slighter  attacks  of  mere 
cervical  catarrh,  which  is  an  extremely  common  malady,  the  hindrance 
to  conception  is  proportionately  less.  With  chronic  endometritis,  if  this 
term  be  applied  to  inflammation  of  the  lining  of  the  uterine  cavity,  the 
influence  on  sterility  is  somewhat  different ;  for,  on  account  of  the  swollen 
condition  of  the  endometrium,  there  is  probably  also  obstruction  to  the 
ascent  of  the  spermatozoa  through  the  uterine  cavity,  and  to  their 
entrance  into  the  tubes ;  especially  if  the  membrane  around  the  orifices 
of  the  tubes  be  involved.  The  inflammatory  secretions  of  the  cavity  are 
also  inimical  to  the  life  of  the  spermatozoa ;  while  a  further  effect  of 
endometritis  is  the  strong  tendency  which  exists  with  it  to  abortion  on 
account  of  the  diseased  endometrium  failing  to  offer  a  safe  nidus  for  the 
support  and  sustenance  of  the  ovum.  The  forms  of  endometritis  known 
as  membranous  and  villous,  and  that  due  to  syphilis,  are  particularly 
hostile  to  the  occurrence  of  pregnancy  ;  and  if  conception  should  occur, 
abortion  is  almost  certain. 

In  chronic  metritis  it  is  probable  that  the  tissue  of  the  uterus  is  never 
affected  without  the  endometrium  being  also  involved,either  in  the  interior 


240  SYSTEM   OF  GYNAECOLOGY 

of  the  body  or  in  the  cervical  canal,  or  in  both.  In  endometritis,  on  the 
other  hand,  the  muscular  tissue  immediately  subjacent  to  the  mucous 
membrane  may  only  be  affected ;  but  it  is  often  the  starting-point  of  a 
general  metritis,  aided  by  abnormal  states  of  the  general  health,  and  by 
certain  conditions  of  the  portal  system  and  heart  which  lead  to  pelvic 
hypersemia.  However  started,  metritis,  when  chronic,  becomes  a  well- 
recognised  cause  of  sterility.  The  term  metritis,  without  reference  to 
the  disputed  point  whether  the  muscular  fibres  of  the  uterus  are  capable 
of  inflammation  in  the  strictly  scientific  sense,  is  here  used  to  include 
the  residts  of  chronic  hyperaemia  in  the  increase  of  connective  tissue 
formation  ;  and  to  include  also  the  condition  sometimes  spoken  of  as 
subinvolution  of  the  uterus,  which  I  believe  to  be  essentially  a  chronic 
metritis  whose  starting-point  has  been  some  traumatic  or  septic  influence 
connected  with  labour.  In  these  conditions  of  uterus  the  sterility 
which  frequently  accompanies  them  is  due  not  merely  to  the  endometrial 
changes  already  referred  to,  which  interfere  with  fertilisation  and  dis- 
pose to  abortion,  but  to  the  slow  inflammatory  changes  which  spread 
to  the  tubes  and  ovaries,  which  interfere  with  ovulation  or  with  the 
transit  of  ova  through  the  tubes,  and,  if  complete,  remove  the  case  from 
the  hopeful  to  the  hopeless  class.  Hyperplasia  limited  to  the  cervix 
would  affect  impregnation  in  so  far  as  the  calibre  and  the  condition  of 
the  lining  membrane  of  the  cervical  canal  are  aifected,  and  in  proportion 
to  the  loss  of  elasticity  in  the  tissues  of  the  cervix  itself. 

Versions  and  Flexions  of  the  Uterus.  —  In  cases  in  which  the  uterus 
is  simply  displaced,  either  backwards  or  forwards,  without  any  bend  on 
its  own  axis,  if  there  be  no  associated  metritis  or  endometritis,  I  do 
not  think  such  displacements  would  have  much  hostile  influence  on 
conception,  unless  a  backward  position  of  the  fundus  with  the  os  directed 
towards  the  anterior  vaginal  wall  should  interfere  with  the  access  of 
spermatozoa  into  the  cervix,  or  should  also  cause  a  displacement  of  the 
ovaries  from  their  normal  relation  to  the  fimbriated  ends  of  the  tubes. 
Possibly  also  displacement  may,  in  intercourse,  prevent  that  adaptation 
of  the  cervix  to  the  male  organ  which  some  writers  hold  to  be  favourable, 
if  not  essential,  to  impregnation,  and  which  by  Rainey  was  believed  to 
be  brought  about,  under  normal  circumstances,  by  the  action  of  the 
round  ligaments.  But  cases  of  version  without  flexion  are  comparatively 
few,  at  all  events  as  regards  cases  of  retroversion,  which,  unless  as  a  stage 
of  prolai)se,  is  rarely  seen  without  some  associated  flexion.  When  versions 
exist  there  is  a  tendency  to  progressive  uterine  hyperemia  with  the 
results,  as  regards  conception,  indicated  under  metritis.  But  where 
flexion  is  added  to  version  and  the  uterus  is  bent  on  itself,  the  tendency 
to  the  dysmenori'hoia  of  uterine  colic  is  rarely  absent,  and  more  or  less  of 
endometritis  and  chronic  metritis  result. 

Anteversion  and  anteflexion  are  recognised  as  but  an  exaggeration 
of  the  normal  state  and  position  of  the  uterus  in  eai'ly  life,  prior  to 
puberty;  and,  in  cases  in  which  this  condition  persists,  the  uterus  as 
a  whole  not  infrequently  remains  infantile  in  character  with  a  small 


STERILITY  24t 

pointed  cervix  and  a  minute  os.  In  these  cases  dysmenorrhoea  is  the 
rule,  and  not  infrequently  amenorrhoea  more  or  less  complete,  showing 
probably  an  immature  condition  of  the  ovaries  also  ;  should  marriage 
take  place,  sterility  is  almost  invariable.  But  these  cases  are  not  hope- 
less. Both  by  medicinal  and  local  treatment  the  condition  may  be 
improved,  normal  menstruation  become  established,  and  the  uterus  and 
its  appendages  may  take  on  a  distinct  if  slow  improvement.  It  has  been 
stated  that  in  rare  cases  versions  may  exist  without  any  associated 
flexion ;  but  still  more  rarely,  if  ever,  is  there  flexion  without  some  co- 
existing version.  And  as  with  anteflexion  there  is  generally  anteversion, 
so  with  retroflexion  there  is  almost  invariably  retroversion ;  but  contrary 
to  what  obtains  in  anteflexion,  retroflexion  is  rarely  congenital.  It  is 
comparatively  rare  in  the  nullipara,  but  in  the  multipara  very  common ; 
and  this  is  so  because  its  most  frequent  starting-point  is  to  be  found  in 
the  conditions  of  the  puerperium.  Its  influence  on  sterility  is  twofold : 
firstly,  the  flexion  as  a  rule  produces  a  virtual  stenosis  of  the  cervix, 
which  constitutes  an  initial  difiiculty  in  the  "way  of  impregnation.  In 
cases  in  which  with  flexion  there  is  no  stenosis  this  difiiculty  of  course 
does  not  occur;  but  where  there  is  stenosis  dysmenorrhoea  is  rarely 
absent ;  and  in  its  train  come,  secondly,  endometritis  and  chronic  uterine 
hyperaemia  with  leucorrhoja,  menorrhagia,  and,  as  a  rule,  sterility.  It 
has  frequently  happened  that  on  reposition  of  the  uterus  and  its  subse- 
quent return  to  a  healthy  condition,  pregnancy  has  resulted  even  after  a 
long  interval  of  sterility.  It  must  not  be  forgotten,  also,  that  if  pregnancy 
occur  in  cases  where  some  retroflexion  exists,  but  in  which  the  uterus 
continues  fairly  healthy,  there  is  always  a  risk  of  its  premature  termination 
by  incarceration  of  the  fundus  in  the  sacral  cavity,  and  by  the  pathological 
changes  which  then  ensue.  The  last  displacement  to  be  noticed  in  con- 
nection with  sterility  is  prolapse.  In  the  various  degrees  of  incomplete 
prolapse  of  the  uterus  there  is  not  much  interference  with  the  possibility 
of  conception  if  the  organ  itself  continue  healthy ;  but  if  prolapse  be- 
come associated  with  chronic  metritis,  a  tendency  to  sterility,  in  propor- 
tion to  the  extent  of  the  metritis,  will  ensue.  In  complete  prolapse 
endometrial  and  metritic  changes  are  generally  present  which,  if  impreg- 
nation took  place,  would  militate  against  a  normal  continuance  of  the 
pregnancy.  But  the  majority  of  these  cases  of  complete  prolapse  occur 
in  women  Avho  have  passed  tlie  usual  limits  of  child-bearing. 

Occasionally  an  elongation  of  the  cervix  takes  place  in  women  after 
child-birth,  which  appears  to  be  secondary  to  congestive  changes  in  the 
cervix  resulting  from  some  pathological  incident  of  labour,  and  resembling 
in  character  those  cases  of  congenital  elongation,  or  infra- vaginal  prolapse, 
which  have  already  been  considered.  In  these  the  tendency  to  sterility 
is  not  so  strongly  marked  as  in  those  of  congenital  origin ;  but  from  the 
accompanying  endometrial  changes  there  is  a  distinct  tendency  to  early 
abortion,  and  so  practically  to  sterility. 

Of  the  uterine  tnmonrs  ichidi  promote  steriliti/  those  requiring  the  chief 
consideration  qxq fibroids  ;  and  their  precise  influence,  as  regards  sterility, 

K 


242  SYSTEM  OF  GYNECOLOGY 

will  depend  not  only  upon  their  size  and  position,  but  also  upon  the  local 
changes  they  produce  within  the  pelvis.  Subperitoneal  pediculated 
fibroids  by  themselves,  if  the  uterus  be  otlierwise  healthy,  will  not 
necessarily  interfere  with  impregnation,  nor  perhaps  with  the  process  of 
pregnancy,  although  there  must  always  be  the  possibility  that  by  some 
casual  twist  of  the  pedicle  uterine  disturbance  may  be  set  up,  and  prema- 
ture labour  either  come  on  or  even  require  induction  if  any  symptoms  of 
strangulation  of  the  fibroid  occur.  A  case  of  this  kind  occurred  in  my 
e.x;perience  where,  even  after  pregnancy  and  delivery  had  been  safely 
accomplished,  an  accident  led  to  partial  severance  of  a  pediculated 
fibroid,  followed  by  intraperitoneal  haemorrhage  and  peritonitis,  which 
necessitated  abdominal  section,  and  hysterectomy. 

When  fibroids  are  situated  in  the  uterine  wall  they  may  have  an 
obstructive  influence  on  the  possibility  of  impregnation  if  their  situation 
be  in  or  near  the  cervix,  and  they  press  upon,  distort,  or  harden  the  canal. 
This,  however,  is  their  least  common  position.  But  not  infrequently,  if 
in  the  anterior  or  posterior  wall,  they  will  also  affect  the  canal,  though 
to  a  less  degree ;  sometimes,  however,  in  the  case  of  multiple  fibroids  to  a 
very  high  degree,  the  uterine  tissue  around  and  between  the  fibroids  being 
dense  and  unyielding  in  character.  But  supposing  this  not  to  be  so,  and 
that  they  do  not  interfere  with  the  physiological  dilatation  of  the  canal, 
and  that  impregnation  occurs,  there  is  still  the  great  probability  that  the 
highly  vascular  and  hypertrophied  lining  membrane,  which  coexists  with 
a  fibroid  projecting  into  the  interior,  and  the  resulting  menorrhagia, 
may  prevent  the  normal  fixation  of  the  ovum.  Even  if  these  initial 
difficulties  do  not  occur,  and  the  ovum  continue  to  develop,  there  are  yet 
great  probabilities  of  early  abortion  or  premature  labour. 

And  beyond  the  influence  upon  the  prospects  of  pregnancy  due  to 
the  efl'ects  of  fibroids  upon  the  uterus  itself,  we  have  also  to  con- 
sider the  effects  of  pressure  exerted  by  them  upon  the  other  pelvic 
viscera,  including  the  tubes  and  ovaries ;  especially  if  the  tumour  be 
large,  or  if  it  be  multiple.  Under  these  circumstances  the  ovaries  are 
not  infrequently  displaced  and  pressed  upon,  and  the  tubes  twisted 
or  flattened ;  and  often  also  more  or  less  pelvic  peritonitis  supervenes, 
leading  to  adhesions  and  matting  together  of  many  of  the  pelvic 
contents. 

In  the  case  of  polypi  a  pediculated  submucous  fibroid  thus  projecting 
into  the  uterine  cavity  has  a  twofold  influence  upon  the  causation 
of  sterility.  If  the  cavity  of  the  uterus  be  much  enlarged,  and  if  the 
polypus  spring  from  the  fundus  and  press  upon  the  orifices  of  the  tubes, 
there  is  a  difficulty  in  the  way  of  the  spermatozoa  either  reaching  or 
entering  the  tubes.  However,  supposing  this  not  to  occur,  and  fertilisa- 
tion to  take  place,  a  difficulty  might  arise  in  the  passage  of  the  fertilised 
ovujn  into  the  uterine  cavity.  It  is  believed,  indeed,  that  in  some 
oases  such  obstruction  has  been  a  cause  of  tubal  gestation.  Su])p()sing, 
lastly,  neither  of  these  obstructive  difficulties  to  occur,  there  would  still 
be  the  endometritic  conditifju  of  iho  lining  membrane  of  the  uterus  to 


STERILITY  243 


contend  with,  kept  up  by  the  presence  of  the  polypus  and  its  attendant 
leucorrhcea  and  inenorrhagia,  both  highly  provocative  of  abortion. 

In  the  case  of  cervical  mucous  polypi  tiie  tendency  to  sterility  is  jjartly 
from  the  obstruction  offered  by  the  polypus  itself  which  may  act  like  a 
ball-valve  against  the  ingress  of  the  spermatic  fluid,  and  still  more  from 
the  catarrhal  condition  of  the  cervix.  In  the  case  of  large  fibroid  polypi 
projecting  through  the  cervix  and  filling  the  vagina,  sterility  is  almost 
certain  until  the  removal  of  the  polypus  has  made  impregnation  possible. 

In  carcinoma  of  the  uterus  in  the  early  stage,  whether  the  disease  have 
attacked  the  vaginal  aspect  of  the  cervix  or  the  cervical  canal,  sterility  is 
certainly  not  absolute.  Pregnancy  in  such  conditions  occasionally  occurs. 
But  in  the  later  stages,  when  the  cervix  is  the  seat  of  a  soft,  friable,  and 
easily  bleeding  papillary  growth,  or  when  its  canal  is  filled  with  a  soft 
vascular  growth,  or  is  excavated  and  granular,  or  again  when  the  body 
of  the  uterus  is  affected,  pregnancy  is  unlikely.  In  many  cases  of 
cervical  carcinoma,  in  which  pregnancy  has  occurred,  the  amount  of  the 
disease  at  the  date  of  fertilisation  was  probably  not  large;  for  its  growth 
is  largely  stimulated  by  the  heightened  uterine  vascularity  which  accom- 
panies gestation.  The  causes  of  the  sterility  in  the  majority  of  cases 
of  carcinomatous  cervix  are  perhaps  partly  mechanical,  according  to  the 
extent  to  which  the  cervix  was  occupied  with  cancerous  growth,  and 
partly  the  effect  of  cancerous  discharges  on  the  vitality  of  the  spermatozoa. 
In  many  cases,  also,  intercourse  is  followed  by  so  serious  and  sometimes 
by  so  alarming  a  hasmorrhage  that  there  is  but  slight  prospect  of  fertil- 
isation. In  cases  in  which  impregnation  does  take  place  there  is  always 
a  tendency  to  abortion. 

4.  Lastly,  in  the  vagina  and  vulva  causes  of  sterility  are  not  infre- 
quently met  with.  Vaginitis  may  be  a  factor  in  the  causation  of  a  tem- 
porary sterility,  both  by  rendering  intercourse  too  painful  to  be  borne, 
and  by  the  excessive  acidity  of  the  inflammatory  secretions  being  fatal 
to  the  spermatozoa.  Undue  shortness  of  the  vagina  and  a  ruptured  peri- 
neum may  also  interfere  with  the  proper  retention  of  the  seminal  fluid. 

Tumours  of  the  vagina,  even  if  innocent  like  cysts  or  fibroids,  offer 
a  mechanical  obstacle  to  normal  intercourse,  and  also,  by  provoking 
an  excessive  leucorrhoeal  discharge,  endanger  the  vitality  of  the  sper- 
matozoa. In  sarcoma  and  carcinoma  of  the  vagina  there  is  an  additional 
adverse  factor  in  the  frequent  haemorrhages  and,  ultimately,  in  the 
necrotic  discharges  which  occur  with  the  advance  of  the  disease.  The 
presence  of  a  vesico-vaginal  fistula  is  not  necessarily,  perhaps,  a  cause  of 
sterility,  but  the  probability  of  its  being  so  is  considerable. 

Certain  diseases  of  the  vidva  are  mainly  operative  by  way  of 
dyspareunia,  which  either  prevents  marital  intercourse  altogether,  or 
renders  it  less  efficacious  for  fertilisation.  Such  are  vulvitis,  especially 
if  it  be  of  the  follicular  type  and  accompanied  by  scattered  small  ulcera^ 
tions  generally  superficial  in  character,  but  highly  sensitive  to  any  touch. 
Cj/stic  enlargement  or  abscess  of  one  of  the  glands  ofBartolini  generally  ren- 
ders intercourse  impracticable  until  it  is  cured.  Eczema  atfecting  the  labia 


244  SYSTEM  OF  GYNECOLOGY 

majora,  with  -svlxicli  is  often  associated  a  sensitiveness  so  acute  that  even 
sitting  is  painful,  often  renders  any  attempt  at  intercourse  impossible. 
Pruritus,  -whether  inflammatory  or  neurotic,  is  likewise  a  cause  of  steril- 
ity in  proportion  to  the  dyspareunia  it  produces ;  and  this  it  is  partic- 
idarly  apt  to  do,  as  the  clitoric  area  of  the  vulva  is  generally  chiefly 
affected.  Caruncle  of  the  urethra  is  another  and  very  persistent  cause 
of  dyspareunia.  So  exquisitely  sensitive  is  it  in  some  cases  that  even, 
the  passage  of  urine  gives  extreme  pain,  and  intercourse  is  impossible. 
Occasionally  on  the  vulva,  and  not  infrequently  on  the  remains  of  the 
hymen,  are  found  little  bright  red  vascular  patches  of  an  extreme  sensi- 
tiveness. Not  infrequently  these  are  gonorrhceal  in  origin,  and  found  in 
association  with  inflammation  of  the  orifices  of  the  ducts  of  Bartolini. 
These  patches  are  exquisitely  sensitive,  and  are  very  generally  barriers  to 
intercourse.  Hypertrophic  enlargement  of  the  labia  majora,  or,  more  rarely, 
of  one  or  other  nympha,  has  occasionally  been  so  considerable  as  to  inter- 
fere with  intercourse.  And,  lastly,  there  is  the  condition  termed  vagi- 
nismus, by  which  is  understood  a  spasmodic  contraction  of  reflex  origin 
of  the  muscular  fibres  surrounding  the  vulval  orifice  of  the  vagina.  In 
a  few  of  these  cases,  and  for  the  most  part  in  patients  of  a  highly  neurotic 
type,  no  local  abnormality  can  be  detected;  but  in  the  majority  local 
pathological  conditions  are  present  which  induce  more  or  less  violent 
spasm  of  the  sphincter  on  the  least  touch.  Whether  the  hyperesthesia 
be  neurotic,  or  dependent  upon  some  obvious  pathological  condition,  the 
resistance  in  some  of  the  worst  cases  to  any  attempt  at  intercourse  is 
extreme ;  the  spasmodic  contraction  at  the  vaginal  entrance  is  violent, 
and,  if  the  attempt  be  persisted  in,  epileptiform  convulsions  or  attacks 
of  syncope  may  occur.  In  these  severer  cases  sterility  is,  of  course, 
invariable.  Occasionally  these  cases  come  before  the  courts  of  law  as 
a  ground  for  divorce,  and  I  gave  evidence  in  one  such  case  in  which, 
for  the  first  time  in  English  law,  a  divorce  was  granted  for  what  was 
but  a  virtual  obstacle  to  the  consummation  of  marriage.  Any  attempt 
at  intercourse  rendered  the  respondent  for  the  time  being  practi- 
cally maniacal.  Among  the  pathological  conditions  which  are  more 
usually  found  to  coexist  with  and  to  induce  this  singular  sensitiveness 
are  an  undue  rigidity  of  the  hymen,  an  inflamed  condition  of  the 
membrane  occurring  either  before  or  after  its  rupture,  unhealed  fissures 
of  the  hymen  following  its  rupture,  eczema  of  the  vulva,  and  small 
ulcers  about  the  inferior  vulval  commissure  or  at  the  edge  of  the  peri- 
neum, vascular  excrescence  of  the  urethra,  fissure  of  the  anus,  and 
occasionally  some  form  of  uterine  displacement  or  periuterine  inflamma- 
tion. 

It  will  he  understood,  of  course,  that  these  contingent  cases  differ 
from  those  of  the  al)Solute  class,  in  that  there  is  always  the  possibility 
of  impregnation  in  spite  of  the  existing  pathological  conditions.  If  in 
spite  of  a  vaginismus  insemination  occur  at  the  orifice  of  the  vagina, 
it  is  quite  possible  for  spermatozoa  to  reach  the  uterus,  and  under 
favourable  circumstances  fertilisation  may  be  effected.     And  in  the  case 


STERILITY 


245 


of  a  cervical  catarrh,  attended  with  tenacious  and  obstructive  discharge, 
occasionally  the  canal  may  be  fairly  healthy,  may  be  free  from  dis- 
charge, may  permit  a  normal  dilatation,  and  fertilisation  become  possible. 

In  the  case  of  vaginismus,  again,  especially  where  the  cause  is  neurotic, 
the  pain  and  consequent  dread  felt  at  one  time  may  be  absent  at  another. 
I  have  known  more  than  one  case  where  sometimes  on  attempt  at  inter- 
course the  patient  has  not  only  resisted  but  violently  attacked  her  hus- 
band, while  on  other  occasions  she  has  received  him  without  opposition. 
In  one  case  of  the  kind  the  patient  would  sometimes  spring  out  of  bed  at 
her  husband's  approach,  while  at  another  time  she  would  be  quiescent 
and  unresisting. 

It  may  be  stated  here  that  neither  sexual  desire  nor  sexual  pleasure 
is  essential  to  impregnation.  Impregnation  has  been  known  to  follow 
criminal  and  forcible  assaults,  with  fright  and  horror  and  suffering  as 
their  necessary  concomitants.  It  is  also  certain  that  desire  maj^  exist 
without  any  pleasure  in  intercourse,  and  that  pleasure  may  occur  with- 
out desire.  Under  various  circumstances,  such  as  unhappiness  in  the 
relations  between  husband  and  wife,  any  feeling  of  desire  may  be  in 
abeyance,  and  yet  the  act  itself  be  pleasurable;  and  sometimes,  even 
if  there  be  a  strong  feeling  of  antipathy  to  the  generative  process  al- 
together, the  act  itself  may  not  be  unattended  with  pleasure.  On  the 
other  hand,  desire  may  exist,  but  from  the  presence  of  some  of  the 
pathological  conditions  named  any  feeling  of  pleasure  may  be  more  than 
neutralised  by  pain  and  suffering.  Occasionally  we  meet  with  patients 
in  whom  there  is  neither  desire  nor  pleasure,  who  are  alwa3'S  apathetic 
and  passive.  But  in  all  these  cases,  whether  desire  or  pleasure  or  both 
be  absent,  fertilisation  may  occur.  In  several  cases  in  which  one  or 
other  or  both  of  these  defects  were  present  in  women  in  whom  pregnancy 
had  not  occurred,  I  have  found  some  condition  present  which,  while 
insufficient,  perhaps,  to  render  intercourse  actively  painful,  has  evidently, 
and  in  a  way  difficult  to  explain,  interfered  with  its  pleasure :  the  ex- 
planation may  be  that  any  faulty  link  in  the  chain  of  incidents  which 
constitutes  the  entire  generative  process  may  interfere  with  the  com- 
pleteness of  those  physiological  sensations  which  accompany  its  initia- 
tion. And  still  further,  I  have  known  several  sterile  women,  with  a 
more  or  less  active  dislike  of  intercourse,  and  to  whom  it  gave  no  pleas- 
ure, who  found  both  pleasure  and  desire  after  some  pathological  condition 
was  remedied,  such  as  a  cervical  stenosis  by  dilatation,  or  a  retroflexion 
of  the  uterus  by  replacement.  But  although  desire  and  pleasure  are  not 
essential  to  impregnation,  there  can  be  no  doubt  that  they  are  favourable 
to  its  occurrence,  as  showing  that  the  organs  concerned  are  healthy,  and 
their  function  likely  to  be  healthily  performed.  The  absence  of  pleasure 
is  probably,  therefore,  significant  of  some  pathological  condition  ;  al- 
though it  is  quite  possible  that  to  ascertain  in  what  it  consists  may  in 
many  cases  be  beyond  our  diagnostic  powers  and  beyond  the  apiilication 
of  any  remedy.  Excess  of  sexual  excitement,  on  the  other  hand,  is 
jirejudicial    to   fertility  in  so  far  as   it   induces   certain   pathological 


246  SYSTEM  OF  GYNECOLOGY 

results,  such  as  a  sustained  congestion  of  the  uterus  and  its  appendages, 
leading  to  ovaritis,  and  with  it  to  defective  ovulation ;  or  to  salpingitis, 
and  with  it  to  more  or  less  obstruction  to  the  descent  of  ova  and  the 
ascent  of  spermatozoa  5  or  to  metritis,  and  with  it  a  tendency  to  the 
occurrence  of  abortion. 

"With  the  treatment  of  these  various  pathological  conditions  this 
article  does  not  deal :  this  is  discussed  in  other  sections  of  this  System 
in  connection  with  the  several  pathological  conditions.  In  cases  of 
absolute  sterility,  whether  congenital  or  acquired,  there  is,  of  course, 
from  their  very  nature  no  treatment  possible ;  but  in  the  larger  number 
of  the  contingent  cases  much  may  be  hoped  for  from  successful  treat- 
ment. Here  the  question  of  diagnosis  is  of  the  essence  of  success :  yet 
in  many  cases  it  is  beyond  our  powers.  A  very  slight  change,  for 
example,  in  the  mutual  relations  of  ovary  and  tube,  quite  beyond  our 
capacity  to  diagnose,  may  prevent  ova  entering  the  tube  and  allow  them 
to  drop  into  the  peritoneal  cavity  and  be  lost ;  or  a  faulty  condition 
of  the  ovary  itself,  depending  possibly  upon  some  defective  local  inner- 
vation, and  beyond  the  scope  of  any  possible  physical  diagnosis,  may  be 
the  cause  of  imperfections  in  the  ova.  In  a  great  many  cases,  however, 
a  painstaking  investigation  will  disclose  some  faulty  link  in  the  chain 
which  connects  insemination  with  fertilisation.  We  must  also  remember 
that  the  causes  of  sterility  may  be  multiple ;  and  that,  because  one  has 
been  removed  without  the  occurrence  of  pregnancy,  it  is  not  necessary 
to  regard  the  case  at  once  as  hopeless.  A  cervical  stenosis  may  be  cured 
by  appropriate  dilatation,  and  yet  imperfect  ovulation,  depending  on 
a  chronic  ovaritis  or  the  condition  of  the  general  health,  may  remain. 
A  dyspareunia,  sufficient  to  prevent  intercourse,  depending  upon  the 
presence  of  a  vascular  caruncle  of  the  urethra,  or  an  inflamed  hymen, 
may  be  cured  by  the  removal  of  the  caruncle  or  the  relief  of  the  local 
inflammation ;  and  yet  conception  may  not  occur  because  of  a  viscid 
catarrhal  discharge  blocking  the  cervical  canal,  or  of  a  gonorrhoeal  sal- 
pingitis which  has  resulted  in  tubal  stenosis.  It  must  not,  of  course, 
Idc  forgotten  that  in  a  certain  number  of  cases  (variously  estimated  at 
from  eight  to  fifteen  per  cent)  it  is  the  husband  who  is  at  fault ;  but  of 
the  nature  and  cause  of  those  faults  no  consideration  is  undertaken  in 
this  article,  which  is  written  from  the  point  of  view  of  the  gynaecologist, 
and  treats  only  of  the  pathological  conditions  with  which  he  has  to  deal. 

A  few  words  may  be  given  to  the  consideration  of  certain  remedial 
measures  Avhich  may  be  proposed,  often  somewhat  empirically,  either 
without  a  sufficiently  careful  investigation  of  the  possible  causes  of  the 
sterility,  or  after  such  investigation  has  disclosed  nothing  obviously 
wrong.  (Certain  watering-places  are  frequently  recommended  as  cures 
for  sterility,  and  in  many  cases  the  diisired  result  has  been  obtained; 
but  probaV)ly  only  when  the  waters  happen  to  be  adaj)ted  to  the  cure  of 
the  pathological  condition  on  which  the  sterility  depends. 

Where  some  chronic  congestion  of  the  pelvic  viscera,  associated  with 
a  gouty  diathesis  or  liver  troubles,  indicates  an  alkaline  and  saline  treat- 


STERILITY 


247 


ment,  Brides  les  Bains,  Kissingen,  and  Ems  may  be  useful.  Where  some 
previous  inflammatory  attack  has  produced  parametric  thickening  of  the 
broad  ligaments,  with  associated  subovaritis  and  metritis,  the  waters  of 
Kreuznach  are  of  distinct  value.  In  cases  of  uterine  fibroids  their  value 
would  appear  to  be  less.  Where  anaemia  exists,  with  scanty  catamenia, 
impaired  general  health,  and  probably  imperfect  ovulation,  the  waters  of 
Franzensbad,  of  SchAvalbach,  of  Pyrmont,  and  of  kSpa  are  indicated.  The 
Marienbad  waters,  including,  as  they  do,  both  alkaline  and  ferruginous 
springs,  can  be  resorted  to  according  to  the  indications  of  the  case  \yide 
art.  "  Balneology,"  Syst.  of  Med.  vol.  i.  p.  318].  And,  lastly,  if  the  gen- 
eral health  be  at  fault,  and  more  especially  the  nervous  system,  Avith- 
out  any  predominance  of  anaemia  or  obvious  pelvic  mischief;  and  if 
there  be  a  dyspareunia.,  of  neurotic  origin,  a  residence  for  a  time  in 
mountain  air  has  been  found  beneficial. 

As  to  medicines  for  sterility,  apart  from  such  as  influence  its  recog- 
nised pathological  causes,  there  is  probably  none  of  any  certain  value  : 
but  possibly  in  some  cases  where,  without  organic  defect  or  functional 
disorder  or  impaired  general  health,  there  may  be  some  limited  failure 
of  ovarian  innervation,  and  so  a  secretion  of  defective  ova,  the  use  of  an 
ovarian  extract  may  be  tried  in  the  same  Avay  as  thyroid  or  thymus  or 
splenic  extracts  have  been  given  in  cases  of  defective  function  in  the 
corresponding  glands. 

Of  artificial  fertilisation  it  need  only  be  said  that  Sims,  who  wrote  on 
this  subject,  appeared  at  one  time  to  have  much  hope  from  its  adoption ; 
but  during  two  years,  in  which  he  carried  out  fifty -five  injections,  he 
succeeded  in  one  case  only,  and  in  this  an  early  miscarriage  occurred. 
He  subsequently  gaveup  the  practice,  and  no  writer  has  advocated  it  siuce. 
The  least  that  can  be  said  about  such  a  suggestion  is  that  it  is  wholly 
empirical.  The  cause  of  sterility  being,  in  the  great  majority  of  cases,  of 
the  contingent  class  of  pathological  origin,  its  remedy  is  to  be  sought 
rather  in  minute  diagnosis. 

Many  of  the  causes  named  are  so  slight  in  themselves,  and  of  such 
slight  importance  to  the  patient's  health,  that  unless  she  seek  advice  on 
account  of  her  sterility  she  may  consider  herself  in  good  average  health  ; 
and  without  any  local  defect  likely  to  be  a  cause  of  sterility.  A  per- 
sistent but  not  excessive  leucorrhoea,  a  moderate  dysmenorrhoea,  a 
tendency  even  to  menorrhagia,  may  all  be  thought  of  little  importance, 
or  not  sufficiently  important  or  unusual  to  need  advice ;  and  yet  may 
be  the  indication  of  a  pathological  condition  adequate  to  account  for 
sterility. 

Two  or  three  points  in  connection  with  the  subject  generally  remain 
for  consideration.  Obesitij  has  been  held  to  be  adverse  to  fertility,  but 
without  any  very  decided  observations  to  support  the  opinion.  Probably 
its  concurrence  with  sterility  may  be  due  to  pathological  conditions  which 
exist  with  the  obesity,  or  as  its  result,  rather  than  to  the  obesity  itself. 
With  obesity  not  infrequently  both  portal  and  cardiac  disorders,  suffi- 
cient to  lead  to  pelvic  congestion,  are  associated;  and,  as  a  result,  dis- 


248  SYSTEM  OF  GYNECOLOGY 

turbed  function  of  tlie  pelvic  organs  ATOuld  follow.  There  would  also  be 
the  possibility  of  a  hea\'y  omentum  pressing  upon  the  pelvic  contents, 
and  interfering  with  the  normal  relation  between  the  ovaries  and 
tubes. 

Tlie  influence  of  alcohol  in  excess  is  also  held  by  some  to  be  adverse 
to  fertility ;  if  so,  this  would  probably  rise  from  a  somewhat  similar 
series  of  pathological  incidents.  Following  upon  portal  congestion  would 
come  congestion  of  the  pelvic  viscera,  with  its  various  adverse  possibilities 
in  connection  with  a  fertile  ovulation ;  and  there  would  also  be  a  gradual 
deterioration  of  the  general  health,  leading  to  disordered  innervation  and 
to  inefB-cient  performance  of  the  functions  of  the  body  generally. 

Excess  or  deficiency  of  menstruation  is  regarded  by  some  writers  as 
unfavourable  to  fertility.  Impregnation  may  certainly  take  place  whether 
the  catamenia  be  profuse  or  scanty  ;  but  both  these  extremes  point  to 
some  pathological  condition  of  the  uterus  or  its  appendages,  or  to  some 
disorder  of  the  general  health  which  may  be  unfavourable  to  con- 
ception. 

The  marringe  of  near  relations  has  also  been  held  to  be  adverse  to 
fertility,  but  probably  without  any  very  good  grounds;  and  when  in 
such  a  case  a  sterile  marriage  has  resulted  it  would  probably  be  explicable 
by  some  pathological  tendency  common  to  both  husband  and  Avife,  and 
affecting  in  a  similar  way  the  various  functions  of  the  body,  and  among 
them  those  of  the  generative  system.  If  both  husband  and  wife, 
though  related,  are  free  from  any  common  diathetic  taint,  and  of  aver- 
age health,  there  is  no  reason  why  sterility  should  attend  their  union. 
Marriarje  icith  heiresses  has  been  regarded  by  some  writers  as  undesirable 
from  the  point  of  view  of  fertility.  If  an  heiress  be  the  sole  survivor  of 
a  family  (and  the  fact  of  her  being  an  heiress  in  many  cases  signifies  as 
much),  this  circumstance  may  indicate  some  family  pathological  tendency 
which  has  led  to  the  premature  deaths  of  other  members  of  the  family: 
these  tendencies  she  may  share,  her  generative  in  common  with  her  other 
functions  may  be  abnormally  performed,  and  her  marriage  from  the 
point  of  view  of  fertility  may  be  undesirable.  But  if  she  have  become 
an  heiress  less  as  a  result  of  an  undue  pathological  mortality  among  the 
members  of  her  family  than  from  accidental  circumstances,  such  as  the 
chances  of  travel,  war,  or  epidemics,  and  if  her  health  be  good,  there 
would  appear  to  be  no  very  valid  reasons  against  her  marrying,  even  if 
the  perpetuation  of  a  family  name  were  specially  desired. 

In  conclusion  it  may  be  remarked  that,  although  with  the  lapse  of 
every  succeeding  year  after  the  third  from  marriage,  without  the  occur- 
rence of  conception,  the  prospect  of  child-bearing  becomes  less,  yet  if  no 
obvious  cause  of  sterility  be  discoverable,  either  absolute  or  contingent, 
the  patient  may  still  be  encouraged  to  entertain  some  hope.  There  are 
sufficient  cases  on  record  of  conception  occurring  after  a  marriage  sterile 
even  for  fifteen  or  twenty  years,  to  prevent  entire  despair ;  a  slight  change 
in  the  mutual  relation  of  the  pelvic  viscera;  a  slight  improvement  in 
some  local  innervation  ;  a  subsidence  of  some  little  chronic  congestion  in 


GYNAECOLOGICAL    THERAPEUTICS  249 

ovary,  tube,  or  uterus,  even  after  the  lapse  of  many  years,  may  rectify 
the  minute  pathological  condition  on  which  the  sterility  depended. 

Henry  Gervis. 

REFERENCES 

1.  Barnes,  Robert.  Diseases  of  Women,  1878.  —  2.  Budin,  Paul.  Obstdtrique  et 
G>/)i^cologie  Recherches  cliniques,  1866.  — 3.  Doran.  Tumours  of  the  Ovary,  1884.  —  4. 
Duncan,  J.  Matthews.  On  Sterilitrj  in  Women,  ISSi.  —  5.  Ibid.  Fecundity,  Fertility, 
Sterility,  1866. — 6.  Galton,  Francis.  Hereditary  Gejiius,  1867.  —  7.  Scanzoni,  F.  W. 
VON.  Diseases  of  Women.  Translated  from  the  French  of  Dor  and  Socin,  1861. — 
8.  Sims,  J.  Marion.     Clinical  Notes  on  Uterine  Surgery,  1866. 

H.  G. 


GYNECOLOGICAL  THEKAPEUTICS 

It  is  a  mistake  to  treat  Gynaecology  as  a  narroAv  specialism.  Successful 
treatment  of  pelvic  disorders  depends  upon  a  correct  view  of  the  organic 
and  functional  integrity  of  the  other  organs  of  the  body.  It  involves 
also  a  somewhat  close  investigation,  and  very  often  considerable  modi- 
hcation  of  the  habitual  regime  of  the  patient.  In  other  words,  it  is 
based  on  general  principles  as  well  as  on  local  lines. 

The  successful  gynaecologist  is  not  one  who  treats  the  pelvic  dis- 
order as  an  isolated  event,  but  who  views  it  either  as  arising  out  of  an 
existing  (or  pre-existing)  constitutional  state,  or  faulty  regime  of  the 
patient;  or,  if  purely  local  in  its  origin,  as  likely  sooner  or  later  to 
injure  the  general  health. 

Frequently  Ave  have  to  deal  Avith  a  ''  vicious  circle,"  AA-ith  local  and 
constitutional  states  so  interacting,  that  no  real  improvement  is  pos- 
sible until  the  "  circle  "  is  broken,  and  both  the  general  and  local  states 
receive  their  due  shares  of  attention. 

Thus  the  circulation,  the  digestion,  and  the  other  important  systems . 
may  influence  or  be  influenced  by  the  pelvic  organs ;    and  the  Avoman 
must  be  treated  as  a  Avhole,  able  only  to  enjoy  perfect  health  as  regards 
one  set  of  organs,  when  all  her  other  organs  are  equally  health}'. 

Professor  Clifford  Allbutt  has  draAvn  attention  to  tlie  influence  of  the 
nervous  system  on  the  symptomatology  and  treatment  of  Gynaecology. 
He  says  "the  uterus  has  its  maladies  of  local  causation,  its  maladies  of 
nervous  causation,  and  its  maladies  of  mixed  causation,  as  other  organs 
have."  This  element  of  neurosis  it  is  AA-hich,  whether  cause,  complicar 
tion,  or  effect,  tends  to  baffle  the  gynaecologist ;  and,  if  disregarded,  will 
prevent  the  complete  cure  of  a  patient  Avhose  pelvic  organs  seem  to  have 
regained  their  organic  and  functional  integrity ;  especially  if  attention 
have  been  paid  correctly,  but  too  exclusively,  to  these  viscera. 

Instances  of  such  complexity  could  be  multiplied  indefinitely,  but 


250  SYSTEM  OF  GYNECOLOGY 

■K^ould  merely  serve  to  emphasise  the  fact  that  general  therapeutics  are 
essential  to  the  efficient  treatment  of  almost  all  cases  which,  owing  to 
the  predominant,  or  perhaps  the  almost  exclusive,  pelvic  character  of 
the  symptoms,  come,  correctly  enough,  under  the  term  "  gyngecological."' 

Notwithstanding  this,  it  is  obviously  impossible  to  do  more  than 
to  indicate  briefly  those  therapeutic  methods  which  are  immediately 
pelvic  in  their  application  ;  and  the  more  general  methods  must  be 
rigidly  omitted  from  consideration. 

Tlie  subject  of  Gynaecological  Therapeutics  may  be  discussed  under  the 
following  subdivisions :  — 

1.  General  Hygiene  (Routine,  Clothing,  Diet,  Baths,  Exercise,  etc.). 
2.  Eest  (General,  Local,  Physiological).  3.  Drugs  (General  and  Special). 
4.  Balneology.  5.  Local  Therapeutical  measures  :  —  (i)  Heat  and  Cold  : 
(a)  External  and  (b)  Internal  application,  (ii)  Medicinal  agents :  (a) 
to  skin;  (b)  to  vulva;  (c)  to  vagina;  (d)  to  uterus.  6.  Blood-letting. 
7.  Operations,  General  measures ;  (i)  Antiseptics ;  (ii)  Preparation  of 
patient;  (iii)  Anaesthesia — (a)  Local,  (6)  General.  8.  Therapeutical 
operations:  (i)  Dilatation  of  uterus;   (ii)  Curetting  the  uterus. 

I.  General  Hygiene.  —  Dr.  Robert  Barnes'  dictum  remains  true, 
"  Occupation,  physical  and  mental,  is  the  great  panacea ;  something  to 
do  is  the  great  female  cry." 

There  are  two  conditions  of  life  which  tend  to  aggravate,  if  not 
actually  to  produce  pelvic  disorders.  The  first  is  luxury,  which  allows 
a  woman  to  spend  her  existence  in  indolence  and  ease,  leaving  her  mind 
a  prey  to  morbid  introspection,  and  her  body  prone  to  functional  debili- 
ties, which  tend  in  the  one  case  to  hysteria,  in  the  other  to  neurasthenia. 
These,  especially  the  latter,  are  much  more  frequently  observed  in  the 
wealthier  classes.  The  second  condition  of  life  which  aggravates  pelvic 
troubles  is  continuous  over-exertion ;  this  is  chiefly  found  in  women  of 
the  poorer  classes,  who  have  not  the  opportunities  of  adequate  rest,  or 
the  change  of  environment  aftfer  illness  and  parturition,  which  their 
richer  sisters  can  ensure. 

The  mode  of  living  ought  then  to  be  between  these  two  extremes  of 
indolence  and  over-exertion.  The  mind  should  be  free  from  anxiety 
.  and  strain,  yet  at  the  same  time  actively  occupied  Avith  some  healthy 
intellectual  pursuit,  which  should  prevent  mental  stagnation  ;  the  body 
should  be  stimulated  by  exercise  suited  to  age,  tastes,  and  circumstances  ; 
and,  above  all,  the  importance  of  functional  regularity  should  be  insisted 
upon. 

The  human  functions  of  menstruation  and  gestation  are  instances  of 
rhythm  in  the  movements  of  nature;  the  intermissions  of  the  hollow 
viscera  occur  in  cycles,  which  are  apj)roximate]y  rliytlimical ;  the  more 
regular  the  woman  in  these  functional  observances  —  in  defaecation, 
micturition,  the  toilet  of  the  skin,  and  exercise  both  mental  and  physi- 
cal—  the  healthier  she  will  be;  and  regularity  of  meals  and  sleep,  both 
as  regards  time  and  duration,  are  no  less  important. 

A  daily  cold  bath  or  cold  sponging  heightens  ai-terial  tone,  strengthens 


G YNM COLO GICAL    THERA PE UTICS 


the  heart's  action,  increases  the  corpuscular  richness  of  the  blood,  and 
the  haemoglobin  richness  of  the  corpuscles,  and  is  at  the  same  time 
a  powerful  nerve  stimulant.  Occasional  hot  baths,  as  means  of  more 
perfect  cleansing,  are  also  essential,  and  should  either  be  taken  just 
before  bed ;  or,  if  at  other  times,  should  be  followed  by  cold  sponging 
and  rough  towelling.  The  daily  routine,  especially  as  to  baths  and 
exercise,  may  need  some  modification  during  the  menstrual  period  or  in 
pregnancy. 

The  women  of  all  centuries  are  affected,  more  or  less,  for  evil  or  for 
good,  by  the  fashions  of  their  generation.  Clothes  should  be  light  and, 
as  regards  underclothing,  loose  in  texture ;  made  either  of  silk  or,  far 
better,  of  wool ;  or,  if  these  cannot  be  worn,  of  loosely  woven  cotton, 
such  as  "  cellular  clothing  "  or ''  flannelette."  Clothes  should  not  prevent 
the  freedom  of  muscular  and  respiratory  action,  and  should  uniformly 
cover  all  parts,  not  leaving  the  genital  organs  to  be  the  least  protected, 
as  in  the  usual  arrangements  of  underclothing. 

Exercise  should  never  be  excessive,  and  should  be  very  moderate  dur- 
ing menstruation.  There  are  certain  forms  of  exercise,  such  as  rowing, 
Avhich  are  less  suited  to  women  than  to  men ;  but  even  these  are  harm- 
less if  taken  carefully  during  menstruation.  Skill  in  such  exercises 
should  be  acquired  in  early  life,  so  as  to  avoid  heavy  strains  and  falls. 
It  should  always  be  remembered  that  active  exercise  in  moderation 
does  far  less  harm  than  passive  exercise ;  for  Avhen  actively  engaged, 
all  the  muscles  of  the  body  are  at  "  attention,"  not  "  off  guard  "  and 
relaxed.  Thus  riding  and  driving  are  often  better  than  being  driven, 
and  bicycling  is  better  than  the  pedal  sewing  machine,  in  which  the  leg 
muscles  only  are  engaged.  In  cycling  it  is  most  important  that  the 
saddle  should  be  wide  enough  to  reach  beyond  the  ischial  tuberosities, 
which  are  wider  apart  in  some  persons  than  in  others;  otherwise  the 
perineum  gets  superficially  hard  and  rigid,  and  the  pelvic  contents  are 
unduly  affected.  Pneumatic  broad  or  double  saddles,  with  a  very 
slightly  elevated  peak,  are  therefore  the  best. 

There  are  other  forms  of  beneficial  exercise,  such  as  dancing,  which 
are  harmful  only  when  indulged  to  excess,  or  in  rooms  where  the  air  is 
rendered  impure  by  overcrowding,  or  by  gas.  Football  and  gymnastics, 
unless  of  the  parlour  variety,  are  quite  unsuited  to  adult  women. 

2.   Rest.  —  General  ;  Local  ;  PInjshlogical. 

In  no  department  of  medicine  is  "rest"  more  essential,  whether  in 
prophylaxis  or  treatment,  than  in  gynaecology.  In  the  pelvis  as  else- 
where, pain  and  disordered  function  are  indications  for  rest. 

Pelvic  rest  may  be  obtained  in  two  ways  :  by  the  complete  quiescence 
of  the  individual,  or  by  a  local  quietude.  The  former  is  a  method  which 
the  leisured  class  can  usually  adopt,  but  is  one  of  which  the  poorer 
classes,  unless  in  a  hospital  or  "  home,"  are  unable  to  avail  themselves. 
For  this  reason  some  surgeons  have  considered  it  right  to  treat  hos- 
pital patients  more  radically  than  private  ones,  and  would,  for  exam- 
ple, remove  the  uterine  appendages  for  certain  varieties  of  tubo-ovarian 


SYSTEM  OF  GYNAECOLOGY 


disease  in  a  woman  whose  livelihood  depends  upon  her  activity ; 
whereas  a  lady  with  leisure  and  means  might  undergo  a  prolonged 
course  of  rest  and  palliative  treatment,  with  a  view,  if  possible,  to  avoid 
that  operation.  As  a  routine  practice  this  is  wrong,  though  in  individ- 
ual cases  it  sometimes  seems  unavoidable.  Each  case  mast  be  judged 
solely  by  its  own  needs,  and  independently  of  the  social  or  domestic 
engagements  and  desires  of  the  patient,  which  often  seem  to  her  more 
important  than  medical  advice. 

Local  rest,  so  useful  in  cases  of  uterine  displacements  with  congestion, 
may  sometimes  be  obtained  by  means  of  the  various  forms  of  pessary, 
which  may  permit  the  patient  to  take  active  exercise,  whilst  the  pelvic 
congestion,  or  the  relaxed  state  of  the  uterine  supports,  are  being  simul- 
taneously improved  by  constitutional  or  other  local  measures.  Such 
'■'  local  "  rest  is  particularly  useful  where  the  patient  belongs  to  the 
working  classes  and  cannot  obtain  "  general  "  rest. 

"Whatever  mechanical  means  be  used,  general  or  local,  physiological 
rest  can  only  be  obtained  by  total  abstinence  from  coitus ;  and  u.nless  the 
husband  Avill  co-operate  in  this  respect,  all  our  efforts  may  prove  fruit- 
less. Sometimes,  however,  it  is  either  unnecessary  or  undesirable  to 
enjoin  sexual  continence. 

3.  Drugs.  —  A  wide  and  precise  knowledge  of  the  action  and  uses 
of  drugs  is  essential  in  the  treatment  of  disease,  whether  of  one  set  of 
organs  or  another.  This  is  especially  true  in  gynaecology,  Avhere,  as 
already  indicated,  so  much  depends  upon  the  functional  and  organic 
integrity  of  the  rest  of  the  individual.  By  the  stimulation  of  extra- 
pelvic  secretory  organs  great  relief  can  be  afforded  to  the  intra-pelvic 
viscera.  A  few  words,  then,  may  be  devoted  to  the  principles  which 
should  guide  us  in  the  administration  of  the  more  general  drugs. 

Purgatives.  —  In  no  class  of  diseases  are  purgatives  more  useful. 
Constipation,  acting  locally  by  the  collection  of  scybala,  may  seriously 
displace  the  pelvic  viscera;  or,  by  exerting  pressure  on  the  venous 
plexuses  round  the  uterus  and  in  the  broad  ligaments,  may  cause  much 
congestion  and  discomfort;  or,  again,  acting  constitutionally,  may  dis- 
pose to  systemic  and  portal  congestion,  which  injuriously  affect  the  pel- 
vic organs.  In  many  cases  of  chronic  pelvic  disease  a  course  of  purgatives, 
such  as  sulphate  of  magnesium,  cascara,  or  aloes,  with  a  few  doses  of 
calomel,  as  occasion  may  require,  will  greatly  relieve  the  patient. 

In  certain  obscure  cases  of  pseudo-ileus  (Olshausen)  Malcolm,  Tait, 
Treves,  and  Lockwood  have  shown  that  a  speedy  evacuation  of  the 
bowel  may  prevent  a  life  being  lost  from  that  form  of  blood-poisoning, 
which  is  caused  by  the  invasion  of  the  system  by  bowel  bacilli  (bac- 
terium coli  commune),  which,  though  always  present  and  usually 
harmless,  may  become  extremely  active  and  virulent  in  disease,  or  even 
on  such  bruising  or  over-stimulation  of  the  intestines  as  may  result  from 
an  undue  manipulation  of  the  Iwwel  during  an  alxlomiiuil  section. 

In  many  cases  of  afuite  pelvic  inflaraination  it  is  far  better  to  keep  the 
bowels  open  daily  by  means  of  a  simple  mixture  of  cascara  and  sulphate 


GYNECOLOGICAL    THERAPEUTICS  253 

of  magnesium,  than  to  keep  the  patient  under  the  influence  of  opiates ; 
it  is  certainly  better  to  do  this  than  to  alternate  the  use  of  opiates  with 
strong  forcing  purgatives  every  two  or  three  days. 

In  suckling  women  purgatives  are  apt  to  affect  the  child.  Castor 
oil  and  calomel  seem,  however,  to  be  exceptions  to  this  rule.  Enemata 
and  rectal  injections  of  glycerine  are  useful  alternatives. 

Tonics  of  all  kinds  may  find  a  place  in  the  treatment  of  pelvic 
disorders. 

AVithout  going  so  far  as  Goodell,  who  says  "  one  cardinal  rule  in 
the  treatment  of  all  uterine  disorders  is  the  internal  administration  of 
iron,  and  of  other  tonics,  unless  contra-indicated,"  there  can  be  no  doubt 
that  iron  is  well  borne  in  nearly  all  such  cases.  Iron  should  be  given 
almost  always  with  purgatives,  otherwise  it  is  often  inert ;  and  in  such 
cases  as  anaemia  and  chlorosis,  with  scanty  or  absent  catamenia,  it  should 
also  be  combined  (Barnes),  with  arsenic  and  freshly  prepared  acetate  of 
ammonia.  The  perchloride  of  iron  is  very  useful  in  cases  of  a  septic 
nature,  as  in  sapraemia  and  septicaemia ;  and  even  in  such  cases  as  peri- 
uterine inflammations,  where  the  "septic"  element  is  not  so  obvious. 
Iron  is  sometimes  ill  borne  in  cases  of  hypertrophic  endometritis,  unless 
the  vascularity  of  the  uterus  be  simultaneously  lessened  by  ergot. 

Permanganate  of  potassium,  in  doses  of  three  grains  (best  combined 
with  unguentum  kaolin  in  the  form  of  a  pill),  is  very  useful  to  increase 
the  effect  of  iron ;  in  cases  of  anaemia  with  amenorrhoea  it  should  be 
given  thrice  daily  for  three  days,  upon  the  date  when  menstruation 
should  appear. 

Arsenic  is  valuable  especially  when  leucorrhoea  is  present  in  anaemic 
girls,  with  a  chronic  catarrh  of  vagina  or  cervix;  in  them  local  treatment 
is  not  advisable  until  a  fair  trial  of  constitutional  treatment  has  first 
been  made. 

Quinine,  which  has  a  special  tonic  action  on  the  uterine  muscle,  is  a 
useful  adjunct ;  and  in  cases  of  debility  or  irritability  of  the  involuntary 
muscles  of  the  body  it  is  usefully  combined  with  strychnine,  arsenic, 
and  some  sedative,  such  as  belladonna,  stramonium,  or  conium. 

Sedatives  must  be  given  with  great  caution.  States  for  which  they 
may  be  indicated  are  often  recurrent;  and  the  repeated  administration 
of  alcohol,  opiates,  etc.,  to  women  whose  nervous  system  is  overwrought 
or  not  under  due  control,  especially  at  the  climacteric,  leads  to  continued 
use,  or  rather  abuse  of  these  agents.  All  such  drugs  should  be  given 
sparingly,  and,  if  possible,  so  disguised  or  given  in  guarded  prescrijv 
tions,  that  patients  may  not  readily  obtain  a  continuous  supply. 

Special  Gyncecologiccd  Drugs.  — There  are  very  few  drugs  for  internal 
administration  which  are  especially  valuable  for  gynaecological  purposes, 
aiid  all  of  them  are  used  for  oth^r  purposes  also. 

The  most  important  of  these  are  ergot ;  cannabis  indica ;  viburnum 
pruuifolium  ;  hydrastis ;  chloride  of  ammonium;  the  bromides;  a  few 
coal  tar  derivatives,  such  as  phenacetin;  chloride  of  calcium;  mercurial 
pre})arations,  and  some  others,  such  as  castor  and  apiol. 


254  SYSTEM  OF  GYNAECOLOGY 

Ergot  of  rye  is  used  for  two  main  purposes  —  to  encourage  uterine 
i-ontraction  and  to  lessen  uterine  haemorrhage.  Its  main  action  is  on  in- 
voluntary muscle  fibres,  causing  a  more  prolonged  and  more  definitely 
intermittent  contraction,  and,  according  to  some  observers,  leading  to  a 
true  tonic  contraction  if  given  in  sufficiently  continuous  or  large  doses. 
Thus  it  is  said  to  act  upon  the  heart ;  it  causes  also  contraction  of  the 
arteries,  and  heightens  arterial  pressure.  It  may  also  cause  some  intes- 
tinal or  vesical  irritation,  and  may  have  to  be  given  with  belladonna  to 
prevent  such  unpleasant  sequences.  Owing  to  its  special  action  on  the 
uterine  muscle  it  is  largely  employed  for  the  treatment  of  passive  ute- 
rine haemorrhage,  or  for  that  due  to  organic  changes,  as  in  uterine  fibroids 
or  fungous  endometritis,  where  diminished  vascularity  tends  to  lessen 
growth.  It  is  also  given  to  promote  indirectly  the  absorption  of  effete 
products,  and  at  the  same  time  to  reduce  uterine  congestion,  by  encourag- 
ing contraction ;  it  may  thus  lessen  the  bulk  of  the  uterus  in  cases  of  sub- 
involution, and  in  cases  of  fibroids  it  may  both  starve  the  tumours  and 
favour  their  extrusion.  Ergot  is  apt  to  increase  the  pain  of  spasmodic 
dysmenorrhoea,  and  may  therefore  have  to  be  omitted  just  before  and  at 
the  commencement  of  a  menstrual  period  :  with  this  occasional  interrup- 
tion ergot  may  be  given  continuously  for  months,  or  even  for  years,  with- 
out deranging  the  health.  Every  now  and  then,  however,  large  doses  will, 
by  contraction  of  the  arterioles,  give  the  heart  more  to  do  than  it  is  equal 
to,  and  it  may  have  to  be  discontinued.  Ergot  should  be  avoided  during 
pregnancy,  except  in  doses  of  5  or  10  drops  in  certain  cases  of  hsemor- 
rhage  (usually  grumous),  where  we  find  on  examination  that  the  uterus 
lias  lost  its  normal  firmness,  its  definite  outline,  and  its  intermittent  con- 
tractions. Ergot  should  not  be  given  during  lactation,  as  it  speedily 
enters  the  milk  and  produces  infantile  colic.  Ergot,  though  usually 
given  by  the  mouth  in  the  form  of  the  liquid  extract,  or  as  ergotin,  may, 
in  either  of  these  forms,  be  subcutaneously  injected,  —  the  former  deep 
into  a  gluteal  muscle,  the  latter  hypodermically,  —  and  though  somewhat 
apt  to  irritate,  can  usually  be  tolerated.  Ergotinine,  in  doses  of  -^-^t\\ 
to  -^T^th  of  a  grain,  is  also  useful  hypodermically,  but  though  less  irritat- 
ing, it  is  less  efficacious,  and  is  also  costly.  In  chronic  haemorrhages,  or 
where  given  for  long  periods,  ergot  should  be  combined  with  acids  and 
purgatives;  but  when  given  in  severe  acute  haemorrhage  it  should  be 
combined  with  ammonia. 

Hydrastis  canadensis.  — The  best  preparations  are  the  tincture  (dose 
"Ixx.  to  n^lx.)  and  hydrastine  (gr.  J-  to  gr.  1).  Though  occasionally  dis- 
appointing, this  drug  has  a  decided  ecbolic  action,  and  if  taken  regularly 
will  check  chronic  haemorrhages  not  due  to  serious  organic  changes. 
The  drug  has  also  a  sedative  effect  which  ergot  has  not. 

Cannabis  indica  is  usually  given  in  the  form  of  the  exti'act  (j-  to  -J-  gr.) 
ov  of  tannate  of  cannabin  (gr.  ij.  to  gr.  x.).  It  is  extremely  useful  in  cases 
of  menorrhagia  with  pain,  acting  even  better  than  hydrastis  ;  where  the 
pain  of  dysmenorrhoia  is  present,  as  in  some  cases  of  iil)roids,  it  acts 
far  better  than  ergot,  even  wlicm  belladonna  is  added  to  the  latter. 


GYNMCOLOGICAL    THERAPEUTICS  255 

Indian  hemp  varies  greatly  in  strength,  and  should  be  ordered  from  one 
source ;  it  must  be  remembered  that  it  is  one  of  those  drugs  which  are 
apt  to  affect  certain  women  peculiarly,  and  at  first  must  be  given  cau- 
tiously in  small  doses.     Vertigo  is  a  frequent  symptom  of  an  overdose. 

Viburnum  prunifolium  is  an  antispasmodic,  relieving  painful  con- 
traction and  cramps  both  of  voluntary  and  involuntary  muscle ;  it  is 
useful,  therefore,  to  prevent  abortion  in  cases  where  uterine  contraction 
precedes  the  death  of  the  foetus  (extract,  dose  gr.  ij.  to  gr.  x.). 

A  large  group  of  antispasmodics  and  sedatives  may  be  used  in  the 
treatment  of  uterine  colic,  but  it  will  suffice  here  to  name  the  good  effect 
which  phenacetin,  antipyrin,  exalgine,  and  other  coal  tar  derivatives,  as 
well  as  apiol  and  castor,  have  in  the  relief  of  all  sorts  of  pelvic  pain, 
including  the  pain  of  dysmenorrhoea,  cancer,  and  neuralgia.  Nitro- 
glycerine (gr.  y^yth)  also  relieves  pain,  and  is  especially  useful  in  the 
last  stages  of  cancer  of  the  uterus,  where  ursemic  symptoms,  such  as 
headache,  scanty  urine,  and  nausea,  may  have  supervened. 

The  bromides  of  potassium  and  ammonium  allay  the  pain  and  general 
restlessness  due  to  increased  local  tension,  as  for  instance  in  cases  where 
congestion  of  the  ovary,  or  rapid  growth  of  a  fibroid,  causes  a  painful 
distension  of  their  enveloping  capsules.  They  also  tend  to  lessen 
haemorrhage  of  a  passive  type,  and  are  particularly  useful  when  taken 
so  as  to  anticipate  menstruation  where  menorrhagia  is  associated  with 
antemenstrual  dysmenorrhoea,  headache,  and  nausea. 

Chloride  of  ammonium  has  also  good  effect  in  relieving  pelvic  con- 
gestion, probably  by  its  action  on  the  liver,  and  is  therefore  useful  in  all 
cases  where  the  vascularity  of  the  pelvis  is  increased,  as  in  fibroids, 
subinvolution,  chronic  metritis,  and  simple  congestion. 

Chloride  of  calcium,  in  doses  of  10  to  20  grains  thrice  daily  for  two 
or  three  days,  answers  like  a  charm  in  some  cases  of  menorrhagia,  where 
ergot  has  failed,  though  the  appropriate  class  of  cases  is  not  yet  ascer- 
tained.    It  acts  (13)  by  encouraging  the  ready  coagulation  of  the  blood. 

Perchloride  of  mercury,  and  other  preparations  of  that  metal,  have 
some  special  use  in  promoting  absorption  of  long-standing  inflammatory 
exudations,  such  as  are  found  in  the  chronic  metritis  of  subinvolution,  or 
as  persistent  thickenings  about  the  pelvic  floor,  after  pelvic  inflammation. 

4.  Balneo-therapeutics.  —  Such  a  large  subject  as  this  can  only  be 
very  briefly  outlined,  but  the  following  remarks  and  table  will  not  be 
out  of  place  :  — 

There  are  certain  health  resorts  and  spas,  at  home  and  abroad,  noted 
for  springs  of  water  which  have  been  found  useful  in  pelvic  disorders. 
Some  of  the  best  are  here  tabled,  but  it  must  be  remembered  that  it  is 
often  necessary  to  send  a  patient  to  a  resort  where  the  water  is  suitable 
rather  to  the  constitutional  diathesis  than  to  the  actual  pelvic  condition 
which  may  be  a  complication.  Thus  ana?mic  patients  may  be  sent  to 
Schwalbac'h,  Nauheim,  Levico,  or  Strath]ieffer ;  and  gouty  persons  to 
Wiesbaden,  Homburg,  Bath,  Harrogate,  Kissingen,  and  many  others. 

Sea-water,  again,  is  a  very  good  substitute  where  it  is  not  possible  \o 


256 


SYSTEM   OF  GYNECOLOGY 


go  to  one  of  the  following  or  other  suitable  resorts.  Sea-water,  when 
pure,  is  somewhat  similar  to  Woodhall  Spa  water ;  it  is  rich  in  salines, 
bromine,  and  iodine,  is  a  powerful  hepatic  stimulant  and  purgative,  and 
can  be  used  internally  as  well  as  in  the  form  of  baths  and  douches,  in 
some  cases  of  portal  and  pelvic  congestion,  with  great  advantage. 

The  following  are  some  of  the  baths  which  are  especially  useful  in 
cases  of  chronic  pelvic  congestion,  subinvolution,  or  fibroids,  and  serve 
to  hasten  complete  recovery  after  acute  inflammatory  attacks,  where 
exudation  into  the  uterine  or  periuterine  tissues  has  been  well  marked. 

[For  a  more  ample  account  of  Balneology  the  reader  is  referred  to  the 
article  by  Dr.  "Weber  in  Syst.  of  Med.  vol.  i.] 

Table  of  Baths  and  Health  Eesoets  for  Chkonic  Pelvic 

Disorders 


Names  of  Places  and  Altitude. 

Season. 

Character  of  Water. 

Special  Uses. 

Bex,  Switzerland,  1400  ft. 

May  to  Sept. 

Saline  water,  bromo- 

Chronic  pelvic  exuda- 

iodurated 

tions.     Fibroids. 

Carlsbad,   Bohemia,   1214 

May  to  Oct. 

Alkaline  saline.    120° 

Chronic    pelvic    con- 

ft. 

F.  to  170°  F. 

gestions.     Gout. 

Contrexeville,        France, 

June  to  Sept. 

Alkaline  effervescing. 

Where  gravel  or  uri- 

1000 ft. 

55°  F. 

nary  diseases  com- 
plicate pelvic  dis- 
orders. 

Franzenbad,       Bohemia, 

May  to  Sept. 

Alkaline  effervescing 

Pelvic         congestion 

1900  ft. 

and  ferruginous 

with  haemorrhoids. 

Kissingen,    Bavaria,    600 

June  to  Sept. 

Cold  saline 

Pelvic         congestion 

ft. 

with  constipation. 

Kreuznach,         Germany, 

May  to  Oct. 

Bromo-iodurated  and 

Subinvolution.     Chr. 

350  ft. 

saline 

inriammation.  Fi- 
broids. 

Marienbad,  Austria-Hun- 

May to  Sept. 

Ferruginous       mud- 

Chronic     exudations 

gary,  910  ft. 

baths 

in  cellular  and 
peritoneal  tissue. 

Plombieres,  France,  1330 

June  to  Sept. 

Ferruginous.     60°  F. 

Chron.    endometritis 

ft. 

to  143°  F. 

with  anaemia. 

Pyrmont,    Germany,    440 

May  to  Sept. 

Effervescing,    ferru- 

Chron.  catarrh  with 

ft. 

ginous,  and  saline 

anaemia. 

Royat,  France,  1480  ft.     . 

June  to  Sept. 

Alkaline,  ferruginous, 

Pelvic        congestion 

and  arsenical.     45° 

with  gout. 

F.  to  95°  F. 

Schwalbach,      Germany, 

May  to  Oct. 

Ferruginous 

Anaemia    with    chro- 

9.55 ft. 

nic  catarrh. 

Salzbrunn,  Bavaria,  2800 

ft. 
Vittel,  France,  1000  ft.     . 

May  to  Oct. 

Iodine  springs   . 

Chronic  congestion. 

June  to  Sept. 

Alkaline  effervescing 

Congestion  with   ob- 

stinate      constipa- 

tion. 

Woodhall,  Lincoln, 

May  to  Oct. 

Saline    bromo-iodur- 

Subinvolution.  Cliro- 

ated 

nic  inflammation. 
Fibroids. 

5.  Local  Therapeutical  Measures.  —  i.     Heat  and  Cold. —  (a)  External 
Applications.  —  Cold  will  excite  reflex  local  contractions  in  both  voluntary 


GYNECOLOGICAL    THERAPEUTICS  257 

and  involuntary  muscle.  In  vigorous  persons  it  increases  the  exhalation 
of  carbonic  acid.  The  effect  of  cold  externally  and  suddenly  applied  is 
well  seen  when  it  is  applied  to  the  abdomen  to  cause  uterine  contraction 
in  post-partum  haemorrhage ;  or  to  the  skin  of  the  new-born  child  to  excite 
diaphragmatic  movement.  The  reflex  effect  of  cold  upon  distant  glandular 
organs  is  less  well  understood;  but  we  know  that  cold  locally  applied 
temporarily  checks  secretion  in  all  the  glands  —  a  check  to  be  followed, 
in  health,  by  a  reactionary  period  of  augmented  secretion. 

Heat,  if  moderate,  is  sedative;  but  if  great,  may  excite  muscular  con- 
traction as  does  extreme  cold,  producing  this  effect  with  less  shock  to  the 
individual.  Hot  baths  are  mainly  sedative,  relaxing  the  skin  and  its 
glands,  dilating  peripheral  vessels,  and  thus  relieving  congestions  of 
internal  viscera :  they  are  useful,  therefore,  in  congestive  dy smenorrhoea, 
prolapsed  ovary,  and  the  like ;  and  are  very  soothing  to  the  flushings, 
the  restlessness,  and  the  irritability  of  the  menopause.  They  also  relieve 
muscular  spasm  and  severe  tension,  and  are  therefore  found  serviceable 
in  spasmodic  dysmenorrhoea,  and  in  cases  of  uterine,  tubal,  intestinal, 
hepatic,  and  renal  colic. 

Hot  foot  and  sitz  baths  act  somewhat  similarly.  In  the  bath,  blood 
is  drawn  from  the  internal  organs  to  the  surface  and  to  the  legs ;  these 
baths  are  therefore  useful  in  relieving  pelvic  congestion,  and  in  cases 
where  the  catamenia  have  been  suddenly  arrested  by  "  a  chill "  with  result- 
ing stagnation  of  the  pelvic  circulation.  After  the  bath  the  blood  re- 
turns more  freely  to  the  pelvis,  the  circulation  of  which  is  re-established  ; 
and  the  menstrual  flow  is  thus  encouraged  to  continue.  Mustard  added 
to  such  baths  increases  these  effects. 

Poultices  and  fomentations,  as  regards  both  their  utility  and  action, 
may  be  considered  as  local  baths.  If  a  sedative  effect  be  required,  bella- 
donna or  opium  may  be  added  to  the  fomentations ;  if  a  stimulating 
effect,  turpentine  may  be  added. 

Poultices  should  be  continuous,  and  should  be  repeated  every  three 
hours,  or  oftener  if  need  be.  If  made  thick  and  covered  with  oiled  silk 
and  flannel,  and  applied  in  the  first  instance 
very  hot,  they  may  remain  somewhat  longer 
at  a  suitable  heat.  If  the  local  relaxation 
produced  by  a  poultice  be  not  Avanted,  a  pad 
about  a  foot  square  can  be  made  by  sewing 
up  some  bran  in  quilted  flannel.  This  can 
be  put  into  the  oven  and  applied  dry, 
or  may  be  kept  hot  by  a  Leiter's  coil. 
By  dipping  this  bran  pad  in  very  hot 
water  it  becomes  a  very  liirht  and  ready 

1^.  '         '  "^  Ki...  .VJ.  —  I.ritor'.-i  coils. 

poultice. 

Leiter's  pliable  metal  coils  (Fig.  52)  have  now  taken  the  place  formerly 
occupied  by  Chapman's  spinal  bags.  Chajunan  showed  that  the  heat  orcold 
of  these  bags  acted  upon  the  spinal  and  ganglionic  nerves  going  to  the  ves- 
sels.   Thus  ice-bags  applied  to  the  lower  dorsal  and  lumber  regions  in  ar- 


258 


SYSTEM  OF  GYNECOLOGY 


rested  raenstruatioii,by  partially  paralysing  tliesevaso-motor  nerves,  andso 
caiising  dilatation  of  the  pelvic  vessels,  encourage  a  freer  pelvic  circulation. 


Fio.  54.  — Hath  speculum. 


Hot  applications  to  the  same  regions  are,  by  analogous  action,  very  use- 
ful in  checking  menorrhagia.  Leiter's  coils  fulfil  those  objects  admirably ; 
and  the  water  can  be  regulated  and  kept  at  any  given  temperature  either 


G  YNMCOLOGICAL    THERAPEUTICS 


259 


by  the  addition  of  ice  to  the  reservoir  of  water,  or  by  a  spirit  lamp  under 
it;  and  cooling  can  be  increased  or  lessened  by  the  rate  at  which  the 
continuous  stream  of  water  is  alloAved 
to  pass  through  the  tubules  of  the  coil. 
The  pliability  of  the  coil  allows  it  to 
be  moulded  to  any  part  of  the  body, 
and  if  the  tubes  be  made  of  alumin- 
ium their  weight  is  trifling. 

For  reducing  temperature,  a  coil  can 
be  moulded  to  the  back  of  the  head, 
and  iced  water  allowed  to  run  through 
it.  For  rallying  a  patient  suffering 
from  shock,  heated  coils  applied  to  the 
feet,  on  the  chest,  and  under  the  arms 
answer  admirably.  If  moist  heat  be 
required  to  imitate  a  poultice,  cloths 
wrung  out  of  warm  water  can  be  wrapped 
round  the  hot  coil. 

(6)  Internal  Applications  of  Heat  and 
Cold.  —  Whilst  in  a  bath,  water  can  be 
made  to  enter  the  vagina  by  means  of  a 
grilled  speculum  (Fig.  54).  The  more 
usual  means,  however,  is  a  douche 
apparatus.  In  all  cases  the  flow  into 
the  vagina  should  be  continuous  —  from 
an  elevated  supply  of  Avater,  as  from  a 
suspended  douche-can,  or  from  an  ele- 
vated syphon  arrangement  (Fig.  55)  ; 
not  intermittent,  as  when  a  hand-ball 
enema  is  used.  If  a  douche-can  be 
the  vessel  employed,  the  outlet  should 
be  slightly  above  the  level  of  its  base, 
lest  imperfectly  mixed  powders,  or  other 
ingredients,  should  escape  in  too  con- 
centrated a  form. 

If  cleansing  alone  be  needed,  two 
or  three  pints  of  water  are  sufficient ; 
but  for  relief  of  local  congestion  irri- 
gation is  employed,  and  several  pints  are  used  for  twenty  to  thirty 
minutes.  The  value  of  this  procedure,  however,  is  probably  over- 
estimated. 

The  vaginal  nozzle  should  be  of  toughened  glass,  and  capable  of  being 
easily  cleaned.  The  patient  should  lie  flat  on  her  back,  with  the  pelvis 
raised  on  a  bed-bath  (Fig.  5G),  or  projecting  over  the  edge  of  a  couch. 

For  the  mere  application  of  heat,  all  that  is  necessary  beyond  these 
points  is  that  the  temperature  of  the  water  should  be  properly  regulated. 
In  prolonged  douching  for  relief  of  congestion,  lukewarm  water  (95°  F.  to 


Fig.  55.  — Syphon  douche. 


26o 


SYSTEM  OF  GYNECOLOGY 


105°  F.)  is  indicated ;  but  for  arrest  of  hsemorrhage,  or  tlie  production  of 
muscular  or  vascular  contraction,  a  temperature  of  118°  F.  is  required. 
Extremely  cold  water  will  also  clieck  lia?morrliage,  though  it  will  not  pro- 
mote coagulation  of  the  blood ;  it  is,  however,  obviously  unsafe  to  em- 
ploy it,  as  it  may  unduly  check  secretion,  or  prevent  the  menstrual  flow 
from  appearing  if  due.  It  is  also  much  more  trying  to  the  general 
health  of  the  patient,  and  water  at  so  low  a  temperature  is  not  readily 
obtainable. 

It  must  be  remembered,  however,  that,  in  addition  to  the  thermal 
properties  of  the  vaginal  douche,  it  also  has  a  very  well-marked  mechanical 
action.  This  is  best  obtained  by  so  elevating  the  douche-can  as  to  make 
the  continuous  current  of  water  somewhat  forcible,  and  capable  of  bal- 
looning the  vagina.     This  action  raises  the  uterus  with  its  appendages 


Fig.  5C.  —  Bed-bath 


and  the  other  pelvic  contents,  empties  engorged  lymphatic  vessels,  glands, 
and  distended  veins,  and  gently  stretches,  and  perhaps  promotes  the 
absorption  of  chronic  inflammatory  thickenings. 

This  ballooning  of  the  vagina  can  be  increased  by  further  elevation  of 
the  reservoir,  or  by  the  patient  arresting  the  outflow  of  the  water  from 
the  vagina  by  hand  pressure  on  the  vulvar  orifice. 

By  the  addition  of  medicinal  agents  the  douche  can  be  rendered 
antiseptic,  anodyne,  astringent,  or  sedative.  These  further  actions  will 
be  discussed  later  (p.  261). 

(ii)  Medicinal  agents  applied  to  (a)  the  skin;  (li)  the  vulva;  (c)  the 
vagina;  (d)  the  uterus. 

(a)  TIte  Skin.  —  Counter-irritation  to  the  skin  may  be  applied  in 
a  variety  of  ways,  by  such  drugs  as  cantharides,  mustard,  turpentine, 
iodine  liniment,  croton  oil,  and  others  in  ordinary  use. 

They  all  lessen  pain  and  appear  to  check  the  spread  of  inflammation, 
and  also  to  promote  absorption  of  iiifi;i,mmatory  exudations.  These 
results  are  probably  brought  about  by  influencing  the  vaso-motor  nerves; 
but,  by  stimulating  the  skin,  they  lead  also  to  its  increased  vascularity, 


GYNECOLOGICAL    THERAPEUTICS  261 

andpresumablytoarelatively  diminished  vascularity  of  subjacent  tissues. 
It  is  clear  too  that  there  is  some  distinct  action  upon  the  terminations  of 
the  nerve  filaments  from  the  spinal  cord ;  and  for  this  reason  counter- 
irritants  should  be  applied  over  the  position  where  the  nerve  trunks, 
which  supply  the  inflamed  organs,  send  branches  also  to  the  surface  of  the 
skin.  These  areas,  as  Dr.  Head  has  shown,  are  not  necessarily  at  the  site 
of  greatest  pain,  but  where  the  touch  of  a  blunt  point  like  a  pin's  head 
detects  hyperesthesia.  It  is  found  that  these  areas  are  supplied  by  the 
posterior  root  of  the  same  nerve  which  also  sends  sensory  nerves  to  the 
inflamed  viscera.  Thus  the  ovary,  when  inflamed,  causes  referred  pain 
and  cutaneous  tenderness  along  the  tenth  dorsal  area ;  the  nerves  going 
to  inflamed  Fallopian  tubes  are  particularly  associated  with  the  eleventh 
and  twelfth  dorsal  segments  ;  so  also  are  the  nerves  supplying  the  upper 
pa'rts  of  the  cervical  canal  and  the  internal  os :  the  lower  part  of  the 
cervix  is  related  to  the  third  and  fourth  sacral  areas.  Much  valuable 
information  on  this  subject  may  be  found  in  Dr.  Head's  paper. 

It  is  difficult,  of  course,  to  estimate  the  curative  effect  of  counter- 
irritants,  in  those  cases  where  rest  in  bed  is  a  coincident  factor  in  the  treat- 
ment, and  wherever  possible  these  two  means  should  be  associated. 

(6)  Applications  to  the  Vulva.  —  The  various  inflammatory  and  other 
morbid  states  of  the  vulva  are  dealt  with  as  are  other  places  in  the  bod}', 
which  resemble  it  in  being  covered  partly  by  skin,  partly  by  mucous 
membrane,  with  a  good  deal  of  transitional  epithelium  at  the  points  of 
union.  Ointments,  lotions,  fomentations,  and  baths  have  each  their 
appropriate  usefulness.  If  the  vulva  alone  be  affected,  especially  in  young 
children,  baths  form  the  best  means  for  applying  sedative  or  stimulating 
lotions. 

(c)  Applications  to  the  Vagina.  —  Medicaments  may  be  applied  to  the 
vagina  in  many  ways.  Among  them  may  be  mentioned  injections, 
douches,  tampons  of  prepared  wool  or  gauze,  pessaries  made  up  with  cacao 
butter  or  gelatine;  or  applications,  in  the  form  of  ointment,  powder,  or 
solution,  maj^  be  made  to  definite  areas  of  the  vagina  through  a  grilled 
or  duckbill  speculum. 

Douches  are  a  very  convenient  way  of  appljdng  medicaments  to  the 
vagina  where  only  temporary  influence  is  required.  If  used  for  antiseptic 
purposes,  percliloride  of  mercur}^  may  be  used  in  the  proportion  of  1  to 
4000  or  2000 ;  or  if  p^rolonged  use  be  needed,  carbolic  acid  (1  in  100), 
or  tincture  of  iodine  (3j.  to  pint),  or  borax  or  boric  acid  or  izal  may  be 
substituted  in  the  same  proportion.  Condy's  fluid  and  sulphocarbolate  of 
zinc  are  also  useful,  and  creolin,  or  lysol  (1  in  200)  is  more  suitable  before 
a  vaginal  operation  when  it  is  important  that  the  vagina  should  be  soft 
and  supple  ;  most  of  the  other  antiseptics  render  it  temporarily  unyielding 
and  contracted.  For  rendering  the  vagina  absolutely  antiseptic  more 
complete  measures  may  be  needed  (see  p.  270).  Douches  can  be  made 
sedative  by  means  of  the  addition  of  liq.  plumbi  subacetatis  (jij.  to 
Oiij.),  laudanum,  or  liq.  opii  sedativus  (3j.  to  Oj.),  chloral  h3^drate  (gr. 
XX.  to   Oj.),  borax  or  bicarbonate  of   soda  (3ij.  to  Oiij.),  or  Condy's 


262  SYSTEM   OF  GYNAECOLOGY 

fluid  well  diluted.  Of  astringent  preparations,  alum,  sulpliate  of  zinc,  and 
tannin  (in  the  proportion  of  half  a  drachm  to  the  pint)  are  the  best. 

Medicated  pessaries  can  be  used  for  all  purposes.  Absorption  is  slow 
and  imperfect  through  the  vaginal  mucous  membrane,  and  at  least  double 
the  usual  dose  of  a  drug  should  be  thus  administered.  Only  those  drugs 
are  thus  used  which  are  known  to  have  a  local  effect.  They  are  best  com- 
bined with  gelatine  or  Avith  cacao  butter,  the  latter  being  itself  very 
soothing.  The  drugs  most  often  used  as  sedatives  are  cocaoine  (gr.  ij.), 
morphia  (gr.  j.),  extract  of  belladonna  (gr.  ij.),  henbane  extract  (gr.  v.), 
hemlock  extract  (gr.  v.).  Astringent  pessaries  should  be  made  up  with 
cacao  butter;  alum  and  tannin  are  the  agents  most  used. 

If  we  desire  to  relieve  vaginal  congestion,  or  to  encourage  secretion 
f  rom  the  vagina,  a  pessary  of  glycerine  (3iss.)  combined  with  gelatine  (jss.) 
is  very  efficacious.  This  agent  has  one  of  its  most  useful  applications"  as 
a  preliminary  to  rapid  dilatation  of  the  cervix,  the  nurse  being  directed  to 
introduce  the  pessary  up  to  the  level  of  the  cervix  two  hours  before 
the  operation.  If  desired,  drugs  may  be  added  to  these  pessaries  to 
make  them  antiseptic  or  sedative ;  and  it  is  in  this  form  that  ichthyol, 
T^-iij.  ill  each  pessary,  has  its  most  useful  sedative  and  absorbent  applica- 
tion. Ichthyol  pessaries  are  also  very  beneficial  in  subinvolution  asso- 
ciated Avith  endocervicitis  and  granular  erosion. 

Tampons  may  be  employed  to  plug  the  vagina,  or  lightly  to  pack  it ; 
but  they  are  sometimes  used  as  a  convenient  method  of  applying 
medicinal  preparations  to  the  walls  of  that  passage.  For  this  purpose 
gauze  is  easily  applied  saturated  with  varioiTS  ingredients,  such  as  carbolic 
acid,  eucalyptus,  iodoform,  sal  alembroth,  salicylic  acid,  sanitas,  or  thymol ; 
or  plain  gauze  previously  dipped  in  the  desired  drug,  such,  for  instance,  as 
a  4  per  cent  solution  of  ichthyol  and  glycerine,  may  be  used.  Wool  like- 
wise, tied  into  convenient  sizes,  may  be  used,  and  can  be  obtained  saturated 
with  lioracic  acid  or  iodoform,  or  containing  perchloride  of  mercury, 
eucalyptus,  iodine,  carbolic  acid,  or  salicylic  acid.  Wool  tampons  can  be 
made  with  astringents,  such  as  alum  or  tannin,  either  mixed  throughout 
the  wool  or  rolled  up  inside  it.  Wool  tampons  steeped  in  glycerine  may 
be  used  instead  of  glycerine  pessaries,  and  are  very  beneficial  where  the 
uterus  needs  support  and  depletion  at  the  same  time. 

If  it  be  desired  to  elevate  the  uterus,  to  keep  tlie  cervix  forwards  or 
backwards,  or  merely  to  rest  the  uterus  after  some  oj)eration  in  which  it 
has  been  much  drawn  out  of  position,  or  in  which  adhesions  to  other 
viscera  have  been  broken  down,  there  is  no  need  to  jiack  the  vagina  very 
tightly ;  but  this  is  very  desirable  where  there  is  severe  uterine 
haimorrhage,  though  it  is  better  to  plug  the  uterine  cavity  itself,  a 
much  more  certain  haemostatic  procedure. 

If  the  vagina  is  to  be  packed  for  liicinorrhage  it  should  be  rendered 
absolutely  antisej^tic,  and  the  rectum  and  l)]ad(l(!r  should  be  emptied.  The 
patient  should  lie  in  the  Sims'  ])osition,  and  a  du(;kl)i]l  speculum  should  be 
])assed.  A  piece  of  gauze  should  be  inserted  into  the  cervical  canal,  and 
the  pouches  around  the  cervix  should  be  firmly  packed  with  antiseptic 


GYNECOLOGICAL    THERAPEUTICS 


263 


gauze;  a  piece  should  also  be  laid  over  the  cervix.  Pieces  of  wool  rolled 
up  into  cylinders  about  as  large  as  the  first  thumb  joint  should  be  then 
passed  up  and  pressed  firmly  against  this  roof  of  gauze,  and  the  vagina 
completely  filled ;  the  strings  attached  to  the  wool  tampons  should  be 
allowed  to  hang  oiit  of  the  vagina.  As  a  rule  they  should  be  left  in  for 
twenty-four  hours,  and  it  will  generally  be  found  that  the  haemorrhage 
has  been  arrested  by  coagula  in  the  upper  gauze  layers. 

Ointments  containing  useful  drugs  may  be  conveyed  into  the  vagina 
by  ointment  carriers,  such  as  Allingham's  or  Matthews  Duncan's  (Fig.  57). 


Fig.  5T.  —  Ointment  carrier  (Matthews  Duncan's). 

The  basis  of  such  ointments  should  be  lanolinated  lard. 

Direct  applications  of  drugs  can  be  made  through  a  speculum  to  an 3^ 
affected  area  of  the  vagina,  and  in  variety  they  cover  a  wide  range. 
Nitrate  of  silver  up  to  a  strength  of  gr.  x.  to  3j.,  or  an  8  per  cent  solution 
of  sulphate  of  copper,  is  useful 
in  some  inflammatory  states ;  pure 
carbolic  acid,  chromic  acid,  acid 
nitrate  of  mercury,  bromine  dis- 
solved in  spirits  of  wine  (1  in 
4)  are  all  useful,  with  appropri- 
ate precautions,  in  cases  of  new 
growth  or  malignant  ulceration. 

(rf)  A-pplications  to  the  Uterus. — 
Medicaments  used  for  the  vagina 
may  also  be  employed  for  the 
vaginal  portion,  but  more  care  is 
required  for  intra-uterine  appli- 
cations. 

To  apply  substances  to  the 
endocervix  it  must  be  exposed  in 
a  speculum,  such  as  Neugebauer's 
(Fig.  58),  in  a  good  light;  after  its 
lining  membrane  is  wiped  free 
from  mucus,  the  solution  or  pow- 
der should  be  applied  on  a  probe, 
such  as  Playf air's,  armed  Avith  cot- 
ton wool.  The  substances  most 
used  are  aciduni  carbolicum  liquef  actum,  iodised  phenol,^  iodine  liniment, 
iodine  paint  -  or  Churchill's  solution  of  iodine,'''liquor  ferri  perchloridi,  and 

1  Iodine  1  part,  and  liquid  carbolic  acid  4  parts. 

-  Iodine,  iodide  of  potassium,  spirits  of  wine,  and  water,  equal   parts  (Samaritan 
Free  Hospital). 

8  Iodine,  78  grains ;  iodide  of  potassium,  00  grains;  rectified  spirits  to  one  ounce. 


Fir,.  ."JS.  —  Diverpingr  speculum  (Xeugebaur'; 


264  SyST£M  OF  GYNyECOLOGY 

ichthyol  (4  to  10  per  cent  solution).  Another  good  method  is  to  pour 
do'n'u  a  Fergusson's  speculum  a  solution  which  can  be  encouraged  to 
enter  the  cervical  canal  freely  by  means  of  an  armed  probe.     One  of 


\.\.y.\i\i\mmAMw:m;mw 


Fig.  59.  — Playfair's  probe. 

the  best  solutions  for  this  purpose  is  an  8  per  cent  solution  of  sulphate 
of  copper. 

If  there  be  much  congestion,  the  cervix  should  be  first  punctured 
till  it  has  assumed  a  light  pink  colour. 

Where  the  endometrium  is  extensively  inflamed,  or  is  the  seat  of 
adenomatous  overgrowth,  dilatation  and  curetting  become  necessary  ;  but 
there  are  many  milder  inflammatory  conditions  of  the  endometrium,  in 
which  a  cure  can  be  obtained  by  several  careful  applications  of  one  or  other 
of  these  or  other  drugs  to  the  cavity  of  the  uterus.  They  are  best  used 
through  a  Fergusson's  speculum,  and  should  be  carried  into  the  uterus  on 
a  Playfair's  probe  ^  suitably  curved.  The  cervix  should  be  exposed  and 
cleansed,  and  a  sound  passed  to  ascertain  the  exact  uterine  curve.  If  this 
curve  be  acute,  the  cervix  should  be  held  and  drawn  down  by  a  tenaculum 


Fig.  CO.  — Uterine  tenaculum  forceps  (Sims'). 

(Fig.  60)  ;  and  if  the  sound  prove  any  constriction  to  exist,  a  few  bougies 
should  first  be  passed :  indeed,  in  any  case  the  application  of  a  powerful 
medicament  may  usefully  be  preceded  by  a  partial  dilatation,  as  uterine 
colic  is  thereby  prevented  and  good  drainage  facilitated.  Except  in  rare 
cases  these  proceedings  should  be  taken  when  the  patient  is  in  bed  and 
able  to  be  at  rest  for  some  hours.  After  the  application,  it  is  a  good  plan 
to  pass  into  the  uterus,  above  the  level  of  the  os  internum,  a  thin  strip 
of  gauze  or  lint,  soaked  in  iodine  and  glycerine,  to  ensure  a  watery  dis- 
charge and  free  drainage.  It  should  be  removed  in  twelve  hours,  and 
an  antiseptic  douche  given.  When  it  is  advisable  to  apply  a  medica- 
ment over  the  endometrium  only,  it  may  be  done  through  a  cervical 
speculum,  such  as  Atthill's  (Fig.  01). 

'The  host  variety  of  Playfair's  prol)ft  i.s  that  in  Fig.  .'iO.  It  lias  not  a  1)nl1)oiis  end, 
hut  taper.s  sliKhtl.V,  ini'l  the  wool,  thfuifjh  held  sufttciently  iirmly  not  to  come  off  when 
the  prohe  is  withdrawn,  will  come  off  readily  enough  afterwards  without  scissors. 


GYNAECOLOGICAL    THERAPEUTICS  265 

Intra-uterine  injections  sliould  never  be  used  Avitliout  security  of  free 
exit ;  and  in  any  case  no  very  irritating  solution  should  be  injected  lest  sud- 
den uterine  contraction  should 
occur.  It  must  be  remembered 
also  that  occasionally  the  Fal- 
lopian tubes  remain  patent  as 
a  result  of  disease,  or  as  part  of 
a  general  pelvic   subinvolution. 

6.  Blood-letting.  —  Some- 
times it  is  desirable  to  relieve 
congestion  b}^  the  local  abstrac- 
tion   of   blood.      This    may   be 

done     by     applvincr     leeches,     bv        Fig.  6I.  — Intra-uterlnecanula  (AtthUrs);  plalinu;ii 
,.         ■^-^•^.°.  '-^  canula,  with  stilette. 

puncturing,    scariiymg,    or    dry 

cupping ;  or  the  result  may  be  arrived  at  by  the  extraction  of  blood- 
serum,  as  when  blisters  are  applied,  or  when  vaginal  glycerine  tampons 
are  introduced.  Whatever  be  the  precise  method  adopted,  it  should 
either  be  carried  out  at  the  place  actually  conjested,  such  as  the  vulva 
or  cervix  uteri,  or  at  a  part  supplied  by  blood-vessels,  Avhich  are  either 
branches  of  the  same  main  trunk  or  anastomose  freely  with  its  off- 
shoots. 

Thus  leeches  applied  to  the  perineum  relieve  pelvic  congestion,  by 
depleting  the  superior,  median,  and  inferior  hsemorrhoidal  vessels  coming 
from  the  common  iliac,  internal  iliac,  and  pudic  arteries  respectively ; 
betAveen  all  of  which  there  is  free  anastomosis.  Relief  is,  of  course,  thus 
afforded  to  the  portal  as  well  as  to  the  general  system,  as  the  superior 
haemorrhoidal  vein  belongs  to  the  portal,  while  the  middle  and  inferior 
belong  to  the  general  venous  system.  Mr.  Marmaduke  Sheild  has  drawn 
attention  to  the  relief  afforded  to  vesical  and  pelvic  congestion  and  irrita- 
tion by  the  applications  of  leeches  or  counter-irritation  to  the  inside  of 
the  thighs.  This  he  accounts  for  partly  by  vaso-motor  influence,  but 
mainly  by  the  depletion  of  the  capillaries  fed  by  the  pudic  branches  of 
the  femoral,  relieving  thus  the  areas  of  congestion  by  lowering  the  blood 
pressure  in  the  branches  from  the  internal  pudic  of  the  internal  iliac, 
with  which  they  freely  anastomose. 

Leeches  to  the  groin,  can  be  shown  to  act  in  a  similar  manner,  and 
the  signal  relief  thus  afforded  to  SAvollen  ovaries  is  probably  produced  by 
depleting  the  small  twigs  from  the  ovarian  artery  which  pass  along  the 
round  ligament  to  the  inguinal  canal,  as  well  as,  more  indirectly,  through 
the  anastomoses  between  the  superficial  and  deep  epigastric  vessels  and 
deep-lying  twigs  from  branches  of  the  internal  iliac  vessels. 

Leeches  to  the  Cervix.  —  ]-)lood  may  be  abstracted  from  the  cervix  by  the 
application  of  leeches,  by  puncturing,  or  scarification.  Blood  thus  drawn 
relieves  the  whole  pelvis.  The  cervix  is  mainly  supplied  from  the  uterine 
arteries ;  but  these  anastomose  so  freely  with  the  ovarian  and  vesical 
arteries  that  the  relief  becomes  very  general.  The  vagina  should  be 
douched  with  some  warm  antiseptic  solution,  such  as  borax  (3ij.  to  Oiij.), 


266  SYSTEM  OF  GYNAECOLOGY 

the  patient  being  in  bed  in  a  warm  room.  She  should  lie  on  her  side 
Avhilst  a  Fergusson's  speculum  is  passed,  which  should  exactly  embrace 
the  cervix  uteri.  The  cervix  must  then  be  carefully  cleansed,  and  its 
cavity,  especially  in  parous  women,  should  be  occluded  by  some  antiseptic 
wool.  If  it  be  desired  to  apply  the  leeches  to  any  particular  spot  on 
the  vaginal  portion,  they  can  be  passed  down  to  the  cervix  in  a  hollow 
tube,  or  held  lightly  in  a  pair  of  forceps  ;  but  as  a  rule  it  suffices  to  throw 
the  leeches  up  the  speculum,  which  is  kept  well  pressed  up  against  the 
fornices  of  the  vagina.  The  leeches  seize  hold  where  they  will,  and  a 
large  wool  tampon  is  then  passed  up  nearly  to  the  cervix  and  kept  in 
for  ten  or  fifteen  minutes ;  the  wool  is  then  removed,  and  the  leeches, 
probably  then  detached,  can  be  easily  rolled  out.  The  cervix  may  then 
be  painted  with  iodine  solution,  or  an  antiseptic  douche  given.  Care 
should  be  taken  that  the  leeches  do  not  attach  themselves  to  the  vaginal 
wall,  as  serious  ha3morrhage  may  follow  by  perforation  of  a  small  vessel. 
If  a  leech-bite  should  thus  bleed,  pressure  applied  by  means  of  a  vaginal 
tampon,  or  the  application  of  strong  iodine  or  perchloride  of  iron,  usually 
stops  it ;  but  if  these  methods  fail,  a  red  hot  wire,  or  the  point  of  a 
Paquelin's  cautery  knife  at  a  dull  red  heat,  ahvays  succeeds.  Where  the 
parts  are  too  tender  for  a  vaginal  plug  this  method  should  be  at  once 
employed. 

If  it  be  desired  to  keep  up  a  little  oozing  after  leeching  or  punctur- 
ing, warm  douches  may  be  given,  or  a  glycerine  tampon  introduced. 

Puncturing  and  Scarifying  the  Cervix  Uteri.  —  Sometimes  leeching  the 
cervix  appears  to  be  of  less  permanent  good  than  puncturing ;  for  although 
more  blood  is  lost  by  the  former  method,  say  two  drachms  to  each 
leech,  there  is  more  suction  of  blood  to  the  part  than  where  puncturing 
is  employed.  In  cases  of  congestion  of  pathological  origin,  with  marked 
blueness  of  the  cervix,  instantaneous  relief  is  afforded  by  the  abstraction, 
by.  puncture,  even  of  two  or  three  drachms  —  the  cervix  becoming  and 
remaining  pink  :  thus  it  becomes  evident  that  the  circulation,  which  was 
stagnant,  is  restored.  Puncturing  is  done  by  exposing  the  cervix  in  a 
speculum,  rendering  the  surface  antiseptically  clean,  and  then  with  a  long- 
handled  sharp-pointed  knife  (Fig.  G2)  gently  stabbing  the  vaginal  aspect 


Ije  BCALB 

Fig.  62.  —  Utoriiio  scarifier. 

of  the  cervix.  These  stabs  should  be  very  slight  at  first,  so  as  to 
indicate  the  tendency  to  bleed ;  they  may  then  be  increased  in  depth 
and  number  till  the  loss  is  considered  sufficient.  Cross  cuts  (scarifying) 
may  be  (!mi)loyed  instead  of  these  punctures,  or  as  an  addition  to  them. 
The  subsequent  treatment  is  as  for  leech-bites.  Such  an  abstraction  of 
blood  may  be  requii'cd  once  a  week,  for  two  or  three  times,  the  effect 
being  continued  by  drugs,  hot  douches,  and  glycerine  pessaries,  with  rest 
and  diet  according  to  circumstances.     If  much  congestion  be  present  in 


GYNECOLOGICAL    THERAPEUTICS  267 

cases  of  endocervicitis,  or  endometritis,  a  preliminary  puncturing  is 
advisable  before  applying  remedies  to  the  lining  membrane. 

7.  Operations. — General  Measures  :  (i)  Antiseptics.  —  There  is  nothing 
peculiar  to  gynaecology  in  the  rules  of  antisepsis,  except  that  it  is 
more  difficult  to  ensure  absolute  asepsis  in  the  vagina  and  endocervix 
on  account  of  the  folds  and  glands  there  found.  The  importance  of 
antiseptic  vaginal  surgery  cannot,  however,  be  too  strongly  insisted  upon, 
for  it  must  be  remembered  that  there  is  a  direct  communication  between 
the  vulva  and  the  peritoneal  cavity,  with  only  partially  protective 
anatomical  barriers  at  the  hymen,  external  and  internal  os  uteri,  and 
uterine  cornua.  The  danger,  therefore,  of  conveying  infective  or  septic 
products  by  incautious  handling  from  a  lower  to  a  higher  level  of  the 
genital  tract  is  very  evident.  Every  one  has  heard  of  septic  inflammation 
following  the  use  of  a  sound — doubtless  traumatism  plus  sepsis  —  and  it 
is,  of  course,  useless  to  cleanse  the  sound  well  if  it  be  allowed  to  pass 
through  a  septic  vagina  en  route  to  the  uterus.  The  sound  should  there- 
fore either  be  passed  along  an  antiseptically  clean  finger,  and  through  an 
equally  clean  vagina,  or  it  should  be  introduced  through  a  speculum ;  and, 
if  there  be  any  suspicion  of  taint,  it  is  safer  to  pass  afterwards  a  Playf air's 
probe  armed  with  wool  dipped  in  tincture  of  iodine  or  other  antiseptic 
solution.  No  one  nowadays  would  dream  of  dilating  a  uterus  except 
under  strict  antiseptic  precautions ;  yet  similar  precautions  are  rarely 
thought  necessary  for  the  passage  of  the  sound,  where  precisely  identical 
risks  are  run.  Indeed,  the  risk  of  passing  a  sound  may  be  greater, 
because  drainage  may  be  very  incomplete,  and  any  infective  material 
carried  up  is  almost  necessarily  retained  in  the  womb.  Without  anti- 
septics the  most  trifling  operation  on  the  generative  organs  may  end  in 
disaster ;  with  rigid  antisepsis  it  seems  possible  to  do  almost  anything 
with  impunity. 

The  subject  of  antiseptics  may  be  subdivided  as  follows  :  —  (a)  Anti- 
sepsis as  regards  the  operator  and  assistants,  (b)  Antisepsis  as  regards 
instruments  and  sponges,  etc.  (c)  Antisepsis  as  regards  ligatures,  sutures, 
etc.     (d)  Antisepsis  as  regards  the  patient,     (e)  Her  environment. 

(a)  Antise2')sis  as  regards  the  Operator  and  Jiis  Assista^its.  —  The  opera- 
tor's (and  his  assistants')  arms  should  be  bared  to  the  elbow,  and  he  should 
be  covered  with  a  clean  mackintosh  apron  reaching  from  neck  to  ankles. 
The  hands  and  arms  should  be  thoroughly  washed  in  two  basins  with 
soap  and  water,  especial  care  being  taken  of  the  nails.  The  skin  should 
then  be  rinsed  with  clean  sterilised  water,  and  dried  by  a  previously 
sterilised  towel.  In  most  cases  all  that  is  further  required  is  to  steep 
the  hands  for  two  minutes  in  a  1  per  1000  solution  of  corrosive  sublimate 
solution,  and  allow  them  to  dry ;  but  if  the  operation  be  an  abdominal 
one,  further  precautions  are  desirable.  Thus  the  hands  and  arms  may' be 
steeped  in  a  saturated  (4  per  cent)  solution  of  permanganate  of  potash  (the 
resulting  stains  may  be  removed  in  one  minute  by  a  1  in  20  sulphurous 
acid  solution  or  a  saturated  oxalic  acid  solution),  and  finally  in  the 
corrosive  sublimate  solution  as  above.     Sanitas  or  turpentine,  poured  on 


268 


SYSTEM  OF  GYNECOLOGY 


Fig.  C3.  —  Steriliser  for  instruments 
(Harrison  Cripps). 


the  hands  after  an  operation,  render  them,  qnite  free  from  any  offensive 

odonr.     Cold  water  removes  blood  from  skin  better  than  hot. 

(6)    Antisepsis  as  regards  Instmments,  Sponges,  etc.  —  Instruments 

should  be  placed  in  boiling  water  or  steamed  (Fig.  63)  before  as  well  as 

after  the  operation,  and  then  laid  in 
a  tray,  similarly  prepared,  containing 
hot  carbolic  solution,  1  in  40  to  1  in 
20.  Both  corrosive  sublimate  and 
iodine  solution  corrode  steel  and 
plated  instruments,  and  Condy's  fluid, 
lysol,  and  creolin  solution  obscure  the 
transparency  of  the  water.  All  in- 
struments should  either  be  capable  of 
being  taken  to  pieces  and  thus  easily 
cleaned,  or  should  be  made  out  of  a 
single  piece  of  metal,  handles  of  wood 
or  bone  being  avoided.  During  the  op- 
eration all  instruments  should  either 
be  placed  again  in  the  tray  of  carbolic, 
or  they  may  be  laid  upon  a  clean 

towel,  and  dipped  in  the  carbolic  solution  before  being  again  used. 

Extra  care  must  be  taken  to  clean  the  eyes  of  needles  and  the  rough 

surfaces  and  joints  of  needle-holders,  artery  and  other  forceps,  scissors, 

and  the  like.     It  is  important  that  instruments  used  at  an  operation 

should  not  be  allowed  to  dry  before  being  cleaned. 

In  most  operations  sponges  may  be  superseded  by  the  use  of  antiseptic 

wool  carried  on  holders,  or  made  into  pads  or  pledgets.    These  pads  are 

Ijest  made  by  having  gauze  sewn  round  them;    they  should  then  be 

rendered  antiseptic  by  boiling  for  two  hours,  and  kept  in  a  solution  of 

carbolic  acid,  1  in  20,  or  in  sublimate  solution, 

1  in  1000.     ]jefore  use  they  are  wrung  dry, 

and  may  be  employed,  after  careful  recleans- 

ing,  throughout  the  operation.     If  sponges  be 

used  they  should  be  prej^ared  as  follows : 

—  Immediately   after   use   they    should   be 

tlioroughly  cleansed  till  the  water  remains 

untiuted,  and  then  soaked  for  from  two  to 

four  hours  in  four  pints  of  warm  water  (for, 

say,  25  sponges),  in  which  a  handful  of  wash- 
ing soda  has  been  dissolved.     The  sponges 

are  then  removed  and  well  washed  in  three 

or  four  waters  to  remove  sliminess,  and  finally 

soaked  for  twenty-four  hours  in  a  covered 

bowl,    containing    a    1    in    500    sulphurous 

acid  solution,  which  bleaclies  them.     After 

being  well  dried  they  are  wrapped  in  a  sterilised  towel,  or  put  away  in 

a  large  hermetically  closed  glass  jar  (Fig.  04),  with  a  small  quantity  of 


<;hiNS  j;ir  I'nr  hjhjii^ 
WDol-pads,  etc. 


G  YN^COLOGICAL    THERAPEUTICS 


269 


alcohol.  For  some  hours  before  the  operation  they  should  be  soaked  in 
a  1  in  20  solution  of  carbolic  acid,  which  should  be  diluted  with  equal 
parts  of  boiling  water  at  the  time  of  the  operation.  The  nurse  who 
has  charge  of  the  sponges  should  squeeze  them  thoroughly  before  handing 
them  to  the  assistant  operator,  and  during  the  operation  they  should  be 
thoroughly  rinsed  in  hot  carbolic  solution  till  free  from  all  blood,  etc., 
and  then  kept  in  the  1  in  40  carbolic  solution  till  „..,,g^,  ■?.<'%. 
required  for  further  use. 

(c)  Antisejisis  as  regards  Ligatures  and  Sut- 
xires.  —  Silk  Avhen  used  for  ligatures  may  either 
be  left  long,  as  in  vaginal  hysterectomy,  to  come 
away  in  from  five  to  twenty  days;  or  may  be  cut 
short  and  so  gradually  destroyed  by  the  action  of 
leucocytes  after  a  much  longer  period,  —  sixty- 
four  days,  according  to  Thomson  of  Dorpat.  If 
in  the  peritoneum,  they  may  require,  according 
to  Ballance  and  Edmunds,  at  least  500  days  for 
their  complete  absorption. 

The  best  silk  for  internal  ligation  or  suturing 
is  China  twist;  though  when  it  gets  dry,  as  it 
would  if  used  externally,  it  tends  to  kink  and  coil. 
Floss  silk  is  more  apt  to  slip  when  being  knotted. 
Silk  must  be  used  sufficiently  thick  to  be  firmly 
tied,  but  must  not  be  too  thick  to  make  a  deep 
ligatured.  It  will  also  be  noted  that  the  thinner 
rapidly  does  it  come  away  or  get  absorbed. 

In  using  silk  ligatures  be  sure  that  they  have  been  efficiently 
sterilised  (Fig.  Qb),  and  that  they  remain  antiseptic.  As  boiling  per- 
ceptibly weakens  silk,  after  being  so  treated  its  strength  should  be  always 
tested  before  use.     Previous  to  the  operation  the  silk  should  be  well 


groove  in  the  part 
the  silk  the   more 


soaked  in  a  1  per  1000 
corrosive  sublimate  solu- 
tion, or  in  a  1  in  20 
carbolic  acid  solution. 
When  not  being  used  it 
may  be  wound  on  glass 
reels,  and  kept  in  air- 
tight glass  bottles  (Fig. 

Every  operator  has 
his  own  way  of  prepar- 
ing catgut  and  rendering 
it  antiseptic.  It  seems 
best  to  soak  it  in  ether 
(Pozzi)  to  remove  any  grease,  and  so  allow  antiseptics  to  enter  freely 
among  its  fibres.  Then  it  may  be  immersed  for  one  hour  in  a  1  per 
1000  solution  of  corrosive  sublimate,  and  afterwards  rolled  on  glass  plates 


270  SYSTEM   OF  GYNECOLOGY 

or  cylinders,  and  steeped  in  oleum  ligni  juniperi  for  a  week,  to  render 
it  supple  and  flexible ;  it  should  then  be  kept  in  a  mixture  of  rectified 
spirit  and  juniper  oil  (10  per  cent)  in  an  air-tight  bottle  till  wanted. 
Immediately  before  being  used  it  should  be  immersed  in  the  subli- 
mate solution.     Catgut  is  usually  absorbed  in  about  ten  days. 

Silkworm  gut  is  the  most  imperishable  organic  ligature  known.  It 
is  bought  in  bunches  of  50  or  100  strands,  the  curly  ends  of  which  should 
be  cut  off,  and  the  straight  intervening  portions  only  used.  These  should 
be  rendered  antiseptic  by  boiling  in  a  1  in  20  carbolic  acid  solution,  and 
should  then  be  kept  in  long  glass  bottles,  containing  absolute  alcohol, 
for  preservation.  Before  being  used  they  should  be  placed  in  boiling 
water  to  make  them  supple  and  pliable. 

Silver  wire  should  be  kept  in  a  1  in  20  carbolic  acid  solution,  and 
before  being  used  should  be  well  polished  by  friction  with  wash-leather, 
then  boiled,  and  replaced  in  the  carbolic  solution. 

Glass  drainage  tubes  should  be  boiled  in  sublimate  or  carbolic  acid 
solution,  and  india-rubber  tubing  may  be  similarly  treated  for  not  more 
than  fifteen  minutes,  being  subsequently  kept  rolled  up  in  antiseptic 
gauze,  or  in  stoppered  bottles  containing  weak  sublimate  or  carbolic 
solution.  To  preserve  india-rubber  tubing,  oil  of  all  sorts,  iodine,  and 
a  temperature  higher  than  120°  C.  should  be  avoided. 

(d)  Antisepsis  as  regards  the  Patient.  —  Although  the  patient  is  pre- 
pared for  some  days  previous  to  the  operation  by  baths,  yet  much  re- 
mains to  be  done  before  the  skin  and  other  parts  are  really  aseptic. 

a.  Before  Abdominal  Section.  —  There  is  probably  far  more  danger 
to  the  patient  from  infection  from  her  own  skin,  sweat  glands,  and  so 
forth,  than  from  the  germs  which  may  and  do  enter  from  the  atmos- 
phere. The  glands  open  so  freely  on  its  surface  that  it  is  doubtful 
whether  it  be  possible  to  purify  the  skin  perfectly.  The  permanganate 
and  oxalic  acid  method  is  one  of  the  best  methods  for  aiming  at  perfection. 

After  freely  washing  the  skin,  and  especially  the  umbilicus,  with 
soap  and  water,  and  subsequently  with  ether,  to  remove  any  fatty 
material,  the  surfaces  should  be  washed  several  times  with  strong  per- 
manganate of  potash  solution,  which  stains  the  skin  of  a  deep  mahogany 
■colour.  This  discoloration  can  be  removed  by  a  1  in  20  sulphurous  acid 
solution,  by  a  concentrated  oxalic  acid  solution,  or  to  a  less  perfect  ex- 
tent by  sanitas  or  turpentine.  This  should  be  done  some  hours  before 
the  operation,  and  the  aljdomen  should  then  be  covered  by  a  wool  or 
gauze  pad  wrung  out  of  a  1  in  40  carbolic  acid  solution ;  when  this  is 
removed  immediately  before  the  operation  the  skin  should  be  carefully 
washed  with  a  1  in  1000  sublimate  solution. 

(3.  Before  operations  on  the  perineum  or  per  vaginam,  the  niirse 
will  douche  the  vagina  twice  daily  for  two  or  three  days  with  hot 
water  containing  tincture  of  iodine  (1  in  150),  or  carbolic  acid  (1  in  60), 
or  corrosive  suVjlirnate  (1  in  2000);  and  after  carefully  washing  the 
external  genitals  and  perineum,  will  foment  them  with  the  same  sub- 
limate solution.     If  so  directed,  she  will  also  shave  the  vulva  and  peri- 


GYNECOLOGICAL    THERAPEUTICS  271 

neum  before  the  operation.  Three  hours  before  the  operation  the  last 
toilet  should  be  effected,  by  douching  the  vagina  and  washing  the 
genitals  either  with  sublimate,  or  as  indicated  for  abdominal  section  ; 
and  when  so  instructed  she  should  clean  the  vagina  more  thoroughly  by 
manipulation  and  swabbing,  and  pack  it  lightly  with  antiseptic  gauze. 

At  the  operation  the  gauze  should  be  removed,  and  the  vagina 
vigorously  douched  and  well  swabbed  out  with  cotton-wool  pads  satu- 
rated with  1  per  1000  sublimate  solution  ;  the  cervical  cavity  should  be 
similarly  treated. 

In  some  vaginal  operations  a  continuous  stream  of  antiseptic  (carbolic 
or  iodine)  lotion  may  be  kept  running  over  the  parts,  either  by  using 
instruments  hollowed  out  like  a  flushing  curette,  or  by  special  arrange- 
ment. After  the  operation  a  douche  should,  as  a  rule,  be  given,  antiseptic 
dry  pads  applied  to  the  perineum,  and  possibly  a  vaginal  antiseptic 
gauze  tampon  also  employed.  Subsequent  contamination  by  urine  and 
faeces  must  be  prevented  for  some  days  by  catheterisation  and  careful 
cleanliness. 

(e)  The  Surroundings  of  the  Patient.  — Erom  the  antiseptic  point  of 
view  the  room  in  which  the  operation  is  to  be  performed  should  be 
scrupulously  clean  ;  and  as  a  rule,  whatever  the  nature  of  the  operation,  it 
is  desirable  to  operate  in  a  room  apart  from  the  ward  in  which  the  patient 
has  previously  been  sleeping.  After  abdominal  section  the  patient  should, 
if  possible,  be  in  a  room  isolated  from  other  wards  for  some  days. 

The  operation  room  should  be  well  lighted  by  windows,  and  should 
also  be  provided  with  electric  light.  The  walls  of  the  room  and  the 
ceiling  should  be  distempered,  and  its  floor  made  of  concrete  or  polished 
wood-blocks.  For  abdominal  operations  a  room  on  the  top  floor,  with 
a  skylight,  is  very  advantageous.  The  furniture  should  be  scant}",  and 
made  of  glass  and  enamelled  iron,  so  as  to  be  easily  cleaned. 

If  a  case  have  shown  any  evidence  of  a  septic  process  the  ward  must 
be  thoroughly  disinfected,  before  another  case  is  admitted,  by  having  the 
floor  and  furniture  washed  with  sublimate  lotion,  by  having  sulphur 
burnt  in  the  room  with  all  its  outlets  closed,  and  by  having  its  walls  and 
ceilings  freshly  distempered.  The  bed-furniture  should  be  sterilised, 
and  the  mattress  should  be  destroyed. 

It  is  almost  superfluous  to  add  that  the  drainage  of  the  house  must 
be  absolutely  perfect,  and  that  the  water-supply,  both  hot  and  cold,  must 
be  pure  and  ample. 

(ii)  Preparation  of  the  Patient,  apart  from  Antiseptics.  —  When  it  is 
known  that  a  patient  is  to  be  operated  upon  in  a  few  days,  everything 
should  be  done  to  promote  the  functional  activity  of  her  organs  so  that 
she  may  better  Avithstand  the  ordeal  of  the  operation,  and  perhaps  avoid 
a  tedious  convalescence. 

Her  diet  should  be  light  and  nutritious,  with  plenty  of  non-alcoholic 
fluid  to  encourage  the  skin  and  kidneys  to  act  freely.  Warm  baths  at 
bedtime,  with  free  use  of  soft  soap  and  a  brisk  towelling,  should  be 
ordered,  and  the  bowels  should  be  regulated  by  some  such  mild  pill  as 


272  SYSTEM  OF  GYNECOLOGY 

pil.  coIgc.  cum  hyoscyam.  gr.  iv.,  pil.  hydrarg.  gr.  j.,  at  bedtime,  followed 
by  a  seidlitz  powder  in  the  morning.  On  the  morning  of  the  operation 
the  larger  bowel  should  be  emptied  by  an  enema  ;  and  if  it  be  evident 
that  the  rectum  will,  after  all,  be  active  during  the  operation,  it  may  be 
advisable  to  pass  a  suppository  of  pil.  plumbi  cum  opio,  gr.  v.,  two  hours 
beforehand. 

Before  the  operation  a  good  night's  sleep  should,  if  necessary,  be 
ensured  by  means  of  a  harmless  drug,  such  as  30  or  45  grains  of 
bromide  of  ammonium. 

No  solid  food  should  be  administered  for  at  least  eight  hours  before 
the  operation,  though  some  diluted  milk,  or  eg^  and  milk,  or  peptonised 
raw  beef  juice  may  be  given  three  hours  beforehand. 

Immediately  before  the  operation  the  patient  should  either  pass 
water,  or  have  the  catheter  passed  by  the  nurse. 

At  the  time  of  the  operation  the  patient  should  be  warmly  but 
loosely  clothed,  the  exact  details  varying  necessarily  with  the  nature  of 
the  operation. 

The  bed  into  which  the  patient  will  be  put  after  the  operation  should 
be  warmed  by  a  hot  bottle,  which  should  lie  at  the  foot ;  and  an  extra 
blanket  should  be  provided  till  the  skin  acts  freely. 

(iii)  Ancesthesia,  Local  and  General. —  (a)  Local  AnmstJiesia. — Cocaine 
is  the  agent  mostly  used  as  a  local  anaesthetic,  both  for  the  relief  of  severe 
pain,  pruritus,  or  other  form  of  local  hyperaesthesia,  and  also  prior  to 
operation,  where,  for  any  reason,  general  anaesthesia  is  contra-indicated. 

Cocaine  (10  to  20  per  cent)  may  be  painted  on  the  skin  or  mucous 
membrane,  or  may  be  rubbed  on  as  a  lanolinated  ointment ;  after  a  few 
minutes  the  tissue  loses  all  sense  of  contact,  and  becomes  "wooden,"  as 
the  patient  generally  describes  it.  Minor  operations,  such  as  opening  a 
superficial  abscess,  or  cutting  or  burning  off  a  wart  or  a  mole,  can  then  be 
painlessly  performed ;  but  if  the  operation  involve  deeper  incisions,  co- 
caine should  be  injected  hypodermically,  or  better  still,  both  endermically 
and  hypodermically.  To  do  this,  three  or  four  drops  of  a  2  or  even  a  1  per 
cent  solution  should  be  used  for  injection  in  several  places,  at  distances 
of  slightly  over  an  inch  — half  an  inch  radius  from  each  puncture  being 
the  zone  of  absolute  anaesthesia  produced  by  such  an  injection.  This 
anaesthesia  is  produced  in  three  minutes,  and  lasts  about  twenty-five 
minutes,  and  provided  not  more  than  twenty  drops  are  used  at  one 
time,  the  cocaine  is  not  likely  to  produce  any  syncope  or  other  ill  effects. 
Schleich  finds  that  a  -02  per  cent  solution  produces  auaesthesia  after 
injection,  and  even  distilled  water  has  some  anaesthetic  effect. 

After  such  an  injection  of  cocaine,  operations  like  trach(!lorrhaphy, 
perineorrhaphy,  excision  of  a  retention-cyst  of  Bartholini's  gland,  or 
burning  off  a  vascular  urethral  caruncle  may  be  performed  without 
suffering.  It  has  been  asserted,  however,  that  union  is  often  less  com- 
]>lete,  and  repair  less  rapid,  after  operation  performed  with  locally 
induced  anaesthesia,. 

If  a  caruncle  be  present,  anaesthesia  may  be  desired  before  cathe- 


G  YNyE  COL  O  GICA  L    THERAPEUTICS 


273 


terisation,  and  an  ointment  (8  per  cent)  may  then  be  gently  applied  ten 
minutes  beforehand.  A  similar  ointment  may  be  useful  in  cases  of 
vaginismus  or  dyspareunia  from  a  local  hypertesthesia,  coitus  being  thus 
rendered  possible.  For  this  purpose,  as  also  for  the  relief  of  pruritus, 
as  in  kraurosis  vulvae,  its  use  is,  as  a  rule,  but  a  temporary  expedient, 
operative  measures  being  generally  needed  to  effect  a  cure. 

(h)  General  Ancesthesia.  — The  choice  of  the  ansesthetic  is  a  subject 
which  should  not  be  solely  in  the  hands  either  of  the  operator  or  of  the 
anaesthetist,  but  the  operator  should  state  which  anaesthetic  he  prefers. 
If  the  anaesthetist,  after  noting  the  type  of  patient,  and  listening  to  the 
heart  and  lungs,  be  satisfied  that  that  particular  aucesthetic  is  not  contra- 
indicated,  he  will  acquiesce;  if,  however,  he  consider  another  form  of 
anaisthesia  to  be  more  suitable  for  the  particular  patient,  a  friendly  con- 
sultation would  no  doubt  lead  to  the  adoption  of  his  advice.  Some 
operators  pin  their  faith  to  a  certain  form  of  anaesthesia  as  the  best  for 


Fig.  6T. — Junker's  inhaler. 

certain  operations ;  but  inasmuch  as  patients  vary  greatly,  the  choice 
must  ultimately  be  made  after  a  consideration  of  the  patient's  state,  and 
as  the  responsibility  finally  rests  with  the  anaesthetist,  it  is  right  that  he 
should  be  always  consulted  and  his  views  upheld. 

Although  much  depends  on  the  skill  of  the  administrator,  it  is 
probably  true  that  there  is  more  bleeding  during  ether  anaesthesia,  and 
thus,  cct'teris  paribus,  such  operations  as  perineorrhaphy  or  vesico-vaginal 
fistula  are  easier  to  perform  under  chloroform  or  A.  C.  E.  mixture  ; 
sickness  is  usually  more  marked  after  ether,  and  spasmodic,  laboured, 
or  jerky  breathing  is  apt  to  be  present  during  its  administration :  for 
this  reason  many  prefer  chloroform  for  abdominal  operations,  especially 
when  administered  by  means  of  a  Junker's  inhaler  (Fig.  67),  but  it  is 
fair  to  say  that  in  the  administration  of  ether  bj^  a  few  anaesthetists  these 
objections  are  not  experienced.  Ether  should  not  be  used  where  the 
abdomen  is  much  distended,  or  where  from  other,  especiall}'  pulmonary 
conditions,  the  respiration  is  laboured.  In  operations  requiring  very 
deep  anaesthesia  —  as  in  rapid  dilatation  of  the  cervix  uteri  for  digital 
exploration  of  the  uterine  cavity  —  there  is  no  doubt  that  ether  is  safer 


274  SYSTEM  OF  GYNECOLOGY 

than  cliloroforin,  as  it  can  be  "pushed"  to  a  further  degree  without 
risk. 

After  loss  of  large  quantities  of  blood  ether  is  safer  than  chloroform. 

The  scope  of  this  work  forbids  further  reference  to  the  details  of  the 
administration  of  the  various  anaesthetics. 

8.  Therapeutical  Operations.—  (i)  Dilatation  of  the  Uterus.  —  This 
operation  was  introduced  by  Simpson  in  1844,  and  may  be  required  for 
various  purposes.  Dilatation  may  be  complete  so  as  to  admit  the  finger, 
or  merely  partial,  to  facilitate  curetting  or  intra-uterine  medication. 

Complete  dilatation  is  mainly  effected  for  diagnosis  by  digital  ex- 
ploration, or  for  treatment  of  some  condition  otherwise  diagnosed.  It 
is  most  frequently  employed  for  the  purpose  of  discovering  the  cause  of 
an  intra-uterine  haemorrhage;  and  the  dilatation  must,  for  that  object, 
be  sufficient  to  admit  the  introduction  of  the  little,  or  if  need  be,  of  the 
index  finger  of  the  operator. 

Partial  dilatation  is  practised  for  the  treatment  of  some  cases  of 
dysmenorrhoea  and  sterility ;  or  prior  to  the  application  of  some  caustic 
or  counter-irritant  to  the  endometrium  ;  or  for  the  purpose  of  curetting 
in  cases  of  haemorrhage  or  chronic  purulent  endometritis,  where  the 
uterus  is  not  much  enlarged  and  digital  exploration  not  needed. 

In  all  cases,  however,  where  a  diagnosis  cannot  be  made  by  the 
examinations  of  portions  of  the  endometrium  detached  by  the  curette  or 
other  instrument,  or  where  polypus,  carcinoma,  or  other  disease,  cannot 
be  excluded  by  other  evidences,  it  is  far  wiser  to  make  sure  of  the  nature 
of  the  case  by  dilating  so  as  to  admit  the  finger. 

Both  degrees  of  dilatation  should  preferably  be  performed  immediately 
after  the  cessation  of  a  period ;  then  the  cervix  is  softest,  and  is  also 
somewhat  patent.  This  softness  (p.  281)  and  relaxation  are  greatly 
increased  by  the  introduction  of  a  glycerine  tampon  two  hours  beforehand 
by  the  nurse ;  and  dilatation  becomes  still  more  easy  if  the  physician 
insert  into  the  cervix,  as  described  hereafter,  a  piece  of  gauze  saturated 
with  glycerine  and  iodoform  about  six  hours  before  the  operation. 

Methods  of  dilatation :  — 

A.  Gradual  dilatation  :  a.  By  antiseptic  wool  or  gauze.    13.  By  tents. 

B.  Rapid  dilatation :  «.  By  graduated  bougies.  /?.  By  two  or  three- 
bladed  dilators,     y.  By  miscellaneous  methods. 

C.  Combined  gradual  and  rapid  methods. 

D.  Dilatation  with  incision. 

A.  Gradual  Dilatation:  —  a.  By  Antiseptic  Wool  or  Gauze. —  This 
method  was  introduced  by  Vulliet  in  1886,  and  is  easy  of  execution ; 
if  antiseptics  are  rigorously  used,  and  suitable  cases  selected,  no  danger 
should  arise. 

The  vagina  and  vulva  should  be  previously  rendered  antiseptic  hy 
douching  and  washing,  and  the  vagina  teinjiorarily  distended  with  an 
iodoform  gauze  tampon.  The  cervix  should  be  exposed  by  a  Sims'  or  by 
a  diverging  speculum,  such  as  Griffin's  (Fig.  08),  Cusco's  (Fig.  GO),  or 
Neugebauer's  (Fig.  58,  p.  263),  and  the  anterior  \\\)  should  be  seized  by  a 


G  YNM  COL  0  GICAL    THERAPE  UTICS 


275 


volsella  and  held  steady  at  a  somewhat  lower  level  than  normal.     The 
endocervix  should  then  be  cleansed,  and  the  direction  of  the  uterine  canal 


Fig.  CS.  —  GriUin's  speculum. 


Fig.  69.  — Cu.scos  s;)ecaluiu. 


ascertained  by  a  sound ;  if  the  os  interum  be  found  to  be  small,  a  few 
bougies  may  be  passed.  A  strip  of  gauze,  a  quarter  to  one  inch  wide 
(according  to  the  estimated  size  of  the  canal),  is  then  dipped  in  carbolised 
or  iodised  glycerine,  and  is  introduced  by  doubling  it  over  the  end  of  a 
uterine  gauze  applicator  (T'ig.  70).     This  instrument  should  taper  some- 


MiJ:M!IMJJi4JRlJi.t.!!l 


Fig.  to.- — Gauze  applicator  (whalebone). 

what  towards  the  end,  which  should  be  blunt-pointed,  and  not  so  line 
as  to  penetrate  the  gauze.  Gauze  may  also  be  introduced  on  long, 
narrow-bladed  forceps  (Fig.  71). 


Fig.  71.  —  Foiceps  to  introduce  gauze. 


After  the  cervix  has  been  completely  or  even  partially  dilated,  some 
operators  prefer  to  tampon  itscavity  through  a  cervical  speculum  (Fig.  72). 
The  gauze  should  be  carried  u])  to  the  fundus  and  the  probe  withdrawn, 
and  more  gauze  similarly  introduced,  till  the  cavity  is  somewhat  tightly 


276  SYSTEM  OF  GYNECOLOGY 

packed.  Yulliet  preferred  to  dilate  by  wool  tampons,  varying  in  size 
from  a  pea  to  an  almond,  rendered  antiseptic  by  dijiping  in  a  10  per  cent 
ethereal  solution  of  iodoform. 

AMiether  gauze  or  "n-ool  have  been  used  it  is  Avithdrawn  after  twenty- 
four  hours,  and  the  cavity  carefully  cleansed  with  sublimate  SA^abs. 
Fresh  gauze  is  then  similarly  introduced,  and,  after  the  third  introduc- 
tion, the  cervix  will  be  so  softened  and  dilated  as  to  admit  the  finger. 

The  advantage  of  this  method  is  that  it  is  nearly  painless,  but  un- 
less great  care  be  taken  not  to  injure  the  endometrium,  it  is  certainly  not 
free  from  the  risk  of  septic  absorption.  As  a  preliminary  accelerant 
of  rapid  dilatation  it  is  excellent,  but  even  then  great  care  has  to  be  taken 
to  avoid  rough  introduction  of  the  gauze.  To  lessen  this  risk  of  septic 
absorption  through  lesions  accidentally  made,  gauze  should  never  be  thus 
used  if  the  uterine  discharges  be  offensive. 

If  it  be  desired  to  keep  the  uterus  patent  after  either  rapid  or  slow 


Fig.  72.  — Corvical  speculum  (B.iii lock's). 


dilatation,  —  as,  for  instance,  when  it  is  hoped  to  obtain  the  extrusion  of  a 
submucous  fibroid  whose  capsule  has  been  incised,  —  continuous  packing 
of  the  endometrium  will  usually  ensure  the  safety  of  the  patient  in  the 
frequent  case  of  danger  from  sloughing  of  the  fibroid.  Such  packing 
will  further  dilate  the  uterus  and  render  any  subsequent  manipulations 
easier. 

In  some  cases  of  chronic  endometritis  a  partial  dilatation  and  drainage 
by  gauze,  with  the  application  of  iodine  liniment  or  paint  twice  weekly 
whilst  drainage  is  continued,  will  often  cure  the  condition  in  a  fortnight, 
the  patient  meanwhile  keeping  to  her  room.  Curetting  is,  however,  in 
most  cases  far  preferable. 

[i.  Gradual  Dilatation  by  Tents.  —  According  to  More  Madden  sponge 
tents  were  invented  by  Phillip  Barrow  in  1539  ;  but  the  method  was  so 
far  forgotten  that  when  Sir  James  Simpson  revived  their  use,  in  1844,  he 
stated  that  "  intra-uterine  disease  was  generally  considered  beyond  the 
pale  of  any  certain  means  of  detection  or  possibility  of  removal." 

The  tents  mostly  used  are  laminaria  (introduced  by  C.  P.  Sloan  of 
Ayr  in  1802),  s])onge,  and  tupelo.  Gentian  root  and  decalcified  ivory 
are  also  used  by  J-*orak.  Laminaria  tents,  as  sold  by  instrument 
makers,  are  unreliable  as  regards  antisepsis;  and  it  would  l>e  worth 
while  for  any  gynaecologist  who  uses  them  much  to  collect  and  prepare 
his  own,  an  easy  undertaking.  Sponge  tents  are  even  more  difficult  to 
get  antiseptically  clean.  The  results  of  using  tents  not  aljsolutely 
aseptic  are  most  disastrous,  and  have  caused  many  a  death  ;  in  the  i^re- 


G  YNM  COL  O  GICAL    T HER  APE  UTICS 


277 


antiseptic  days,  acute  metritis,  salpingitis,  peri-  and  para-metritis  and 
septic  fever  were  frequent  consequences. 

Laminaria  and  tiipelo  tents  should  be  steeped  in  a  saturated  solution 
of  alcohol  and  corrosive  sublimate  for  two  or  three  hours,  and  then 
allowed  to  dry  before  being  used  ;  sponge  tents  may  be  dipped  in  an 
ethereal  solution  of  iodoform  (10  per  cent),  and  then  dried  by  swinging 
them  round  by  the  attached  string. 

Tents  are  mainly  used  as  a  preparatory  step  to  rapid  dilatation;  but 
they  are  still  used  sometimes  for  completing  dilatation,  and  must  then  be 
repeatedly  introduced  till  the  finger  can  be  inserted.  I  have  not  used  a 
tent  for  several  years,  as  T  fui<l  rapid  dilatation  answers  all  purposes  when 


Fig.  73.  —  Duckbill  speculum  (Sim 


used  with  the  aids  described  on  pages  280-1,  but,  as  it  is  evident  that  tents 
are  still  frequently  used,  full  details  of  their  introduction  are  here  given. 
After  the  tents  and  the  vagina  have  been  prepared,  and  the  patient 
put  into  the  Sims  or  lithotomy  position,  a  duckbill  speculum  (Fig.  73) 
is  introduced,  and  the  cervix  somewhat  lowered  by  a  sharp  hook,  so  as 
to  fix  the  uterus  and  straighten  its  canal.  The  actual  length  and  curve 
of  the  cavity  is  then  ascertained  by  the  sound,  and  the  size  of  the  tent 
which  can  probably  be  introduced  is  roughly  gauged.  A  laminaria  tent 
can  be  curved  by  holding  it  over  a  spirit  lamp  till  hot.  The  cervix  should 
then  be  cleansed  with  sublimate  solution,  and  the  tent  passed  either  on  a 


Fig.  74.  —  IJarnos'  tent  iiitroduciT. 


pointed  introducer  provided  with  a  canula,  such  as  Barnes'  (Fig.  74),  or 
held  in  a  s\iitable  pair  of  forceps,  such  as  Chambers'  (Fig.  75).  It  is  a 
good  plan  to  dip  the  tent  into  pure  liquid  carbolic  acid  before  inserting  it. 


27$  SYSTEM  OF  GYNECOLOGY 

As  large  a  tent,  or  as  many  small  ones,  as  can  be  passed  beyond  the  os 
internum  should  be  inserted  at  once.  The  ends  should  slightly  project 
into  the  vagina.  A  vaginal  antiseptic  tampon  soaked  in  glycerine  should 
then  be  inserted.  The  tents  should  be  left  in  from  eight  to  twelve  hours, 
especially  the  hollow  laminaria  ones,  as  they  do  not  readily  dilate  to 
their  full  extent  at  the  os  internum,  where  there  is  greatest  resistance 
To  extract  a  tent,  all  that  is  necessary  is  to  draw  upon  the  string  at- 
tached to  the  vaginal  end ;  but  if  the  tent  has  not  dilated  well  at  the 
level  of  the  os  internum,  forceps  must  be  used  to  pull  and  lever  it  out, 
whilst  counter-pressure  is  exerted  upon  the  cervix  by  the  linger. 

To  admit  the  exploring  finger  into  the  uterus,  one,  or  often  two 
repetitions  have  to  be  made.  This  should  only  be  done  after  careful 
antiseptic  cleansing  both  of  the  vagina  and  uterine  cavity  ;  and  then  as 
many  fresh  tents  as  can  be  introduced  should  be  simultaneously  inserted. 


Chambers'  tent  introducinjj  forcepi 


If  only  a  slight  further  dilatation  be  necessary,  and  ra])id  dilatation 
be  not  available,  a  tupelo  tent  is  better  than  another  series  of  laminaria, 
as  it  dilates  more  rapidly  and  more  evenly,  can  be  obtained  of  larger 
size,  and  be  more  efficiently  rendered  antiseptic.  By  this  time,  especially 
if  a  third  series  of  tents  have  been  introduced,  the  temperature  may  have 
risen,  the  patient  will  be  irritable  and  restless  and  sometimes  nauseated, 
and  not  in  the  best  condition  to  undergo  a  prolonged  examination  for 
the  purpose  of  treating  whatever  conditions  may  be  found. 

In  the  old  days,  when  the  uterus  w"as  always  dilated  with  tents,  it  was 
not  often  that  any  condition  was  found  which  recpiired,  or  at  all  events 
was  treated  by  curetting ;  this  is  to  be  explained  by  the  fact  that  the 
prolonged  pressure  of  three  series  of  tents,  with  the  application  of  the 
intra-uterine  counter-irritants  subsequently  used,  would  destroy  any  of 
the  more  ordinary  hypertrophic  f ungosities  found  in  so-called  "  fungous 
endometritis,"  and  would,  if  no  accidents  followed,  tend  to  promote 
absorption  of  inflammatory  exudations  in  the  parenchyma  of  the  organ. 
In  curetting  we  have  now,  however,  a  much  more  rapid  and  effectual 
method  of  dealing  with  these  conditions. 

Tents  should  never  be  used  if  the  uterine  discharges  are  offensive,  as 
the  absorption  of  pent-np  putrescent  secretions  may  lead  both  to  local 
septic  inflammation  and  to  a  general  septicaemia;  and,  even  recently, 
deaths  have  been  described  as  having  occurred  under  these  conditions.  1 
refer  to  such  cases  as  cancer  of  the  body  of  tlie  nterus,  sloughing  polypus, 
and  even  to  some  cases  of  fungous  endometritis  in  which  the  polypoidal 


GYNECOLOGICAL    THERAPEUTICS  279 

villous  processes  of  gland  tissue  have  either  become  ulcerated  or  have 
superficially  sloughed.     Ko  tent  should  ever  be  used  twice. 

It  must  be  remembered  that  the  danger  of  sepsis  is  not  over  when  the 
tents  have  been  removed,  as,  especially  with  sponge  tents,  small  pieces 
are  apt  to  remain  in  the  folds  of  the  lining  membrane,  and  will  there 
decompose  and  cause  a  local  absorption.  It  is  therefore  most  important 
that  after  the  withdrawal  of  tents  some  strong  antiseptic  should  be 
carried  up  into  the  uterine  cavity,  such,  for  instance,  as  iodine  liniment 
or  iodised  phenol ;  and  that  drainage  should,  for  twenty-four  hours,  be 
maintained  by  passing  up  into  the  uterus  a  thin  strip  of  iodoform  gauze 
soaked  in  iodised  glycerine. 

Every  now  and  again  it  is  found  that  the  effect  of  the  introduction  of 
a  tent  upon  the  nervous  system  is  considerable ;  the  patient  becomes 
extremely  restless,  or  vomits  incessantly,  or  the  temperature  rises  imme- 
diately, or  at  all  events  too  soon  for  it  to  have  a  septic  origin ;  a  few 
cases  of  convulsions  have  been  described,  and  one  or  two  of  tetanus.  In 
one  case,  treated  by  myself,  the  temperature  rose  to  107°  F.  within 
thirty  minutes  of  the  insertion  of  the  tent ;  but  under  the  influence  of 
a  hypodermic  injection  of  morphia  it  gradually  fell,  and  by  the  next 
morning,  on  removal  of  the  tent,  it  was  99°  F.  ;  the  patient  recovered 
without  further  trouble.  Bromide  of  potassium  is  very  useful  to  control 
this  hypergesthesia  and  excitement. 

B.  Rapid  Dilatation.  —  Dilatation  by  tents,  except  as  a  preliminaiy 
step,  having  now  been  almost  universally  given  up,  all  the  exploratory 
and  therapeutical  dilatations  are  performed  either  entirely,  or  in  the 
main,  by  one  or  other  of  the  rapid  methods.  Whereas  it  used  to  take 
from  twenty-four  to  forty-eight  hours  to  dilate  the  uterus  sufficiently  to 
admit  the  exploring  finger,  it  is  now  done  with  far  less  risk  in  from 
twenty  to  sixty  minutes. 

Indications  for  Rapid  Dilatation.  —  Rapid  dilatation  may  have  to  be 
done  for  the  treatment  of  some  forms  of  dysmenorrhoea,  as  for  instance  in 
some  cases  of  the  spasmodic  or  of  the  obstructive  type,  and  especially  in 
cases  of  membranous  dysmenorrhoea ;  as  a  preliminary  step  to  a  thorough 
application  of  some  medicament  to  the  endometrium,  or  antecedent  to  a 
subsequent  curettage  ;  or  in  some  of  those  rare  cases  wliere,  according  to 
Schultze,  it  is  advisable  to  dilate  the  uterus  sufliciently  to  admit  the 
finger,  with  a  view  to  breaking  down  retro-uterine  adhesions  by  manipu- 
lation, and  so  to  perform  "  intra-uterine  reposition."  The  main  object  of 
rapid  dilatation,  however,  is  to  enable  the  finger  to  be  introduced  for  the 
purpose  of  making  a  diagnosis  of  the  intra-uterine  condition  in  cases  of 
uterine  lueiuorrhage,  where,  in  the  absence  of  any  constitutional  cause  or 
obvious  local  extra-uterine  disease,  a  further  examination  is  indicated. 

Assuming,  then,  that  a  Avoman  comes  for  treatment,  one  of  whose 
chief  symptoms  is  menorrhagia  or  metrorrhagia,  inquiries  would  bo  made 
as  to  any  constitutional  cause,  and  a  vaginal  examination  would  bo  made, 
unless  contra-indicated  by  virginity  or  youth.  In  all  cases  of  ha?morrhage 
after  the  menopause,  or  even  in  cases  of  severe  hsemorrliage  before  that 


2So  SYSTEM  OF  GYNECOLOGY 

time  of  life,  a  vaginal  examination  should  be  insisted  upon  to  make  the 
diagnosis  sure.  ■  Possibly  some  obvious  cause  of  haemorrhage  would  thus 
be  discovered,  such  as  cancer  or  adenoma  of  the  cervix  or  vagina,  adhesive 
ulcerative  vaginitis,  severe  erosion  of  the  vaginal  portion,  ulceration  from 
foreign  bodies,  an  extruding  fibroid,  a  cervical  mucous  polypus,  ulcerating 
procidentia,  or  inversion  of  the  uterus.  The  possibility  of  a  molar  preg- 
nancy, a  threatened,  incomplete,  or  missed  abortion,  or  the  existence  of 
a  mole  or  an  endometritis  of  the  gravid  uterus,  must  not  be  overlooked. 

A  bimanual  examination  would  further  serve  to  limit  the  diagnosis, 
when  the  uterus  might  be  found  uniformly  enlarged  by  subinvolution,  or 
irregularly  so  by  intramural  fibroid ;  or  some  tubal  or  other  perimetric 
disease  might  be  found  to  account  for  the  haemorrhage.  If  none  of  these 
obvious  causes  were  discovered  the  sound  might  be  passed,  whereby  the 
size  and  shape,  and  any  considerable  roughness  and  vascularity  of  the 
endometrium  would  be  discovered.  If  the  uterus  be  not  enlarged  con- 
stitutional treatment  may  be  tried ;  or  if  an  ordinary  endometritis  be 
diagnosed  in  a  small  uterus,  a  partial  dilatation,  prior  to  the  use  of  some 
counter-irritant,  may  be  effected  without  anaesthesia,  or  after  the  local 
application  of  a  10  per  cent  solution  of  cocaine.  Even  if  the  uterus  be 
irregularly  enlarged,  and  intra-mural  fibroids  be  diagnosed,  it  must  not 
be  assumed  that  the  haemorrhage,  which  is  probably  the  main  symptom,  is 
to.be  dealt  with  by  a  serious  operation  like  oophorectomy  or  hysterectomy, 
for,  as  I  (25)  have  elsewhere  shown  —  in  a  series  of  consecutive  cases 
dilated  for  haemorrhage  —  88  per  cent  of  the  cases  of  fibroid  viterus  thus 
treated  contained  a  removable  cause ;  that  is,  they  were  found  compli- 
cated with  fungous  endometritis,  polypus,  or  the  two  combined,  and  were 
thus  capable  of  immediate  relief,  so  far,  at  least,  as  the  immediate  symp- 
tom of  haemorrhage  was  concerned.  By  this  means  the  patient  would 
often  be  steered  safely  over  the  menopause. 

Many  cases  are  now  on  record,  and  others  are  within  the  knowledge  of 
all  gynaecologists,  where  haemorrhage  has  persisted  after  oophorectomy, 
and  has  Ijeen  subsequently  cured  by  the  removal  of  an  intra-uterine 
polypus  after  exploratory  dilatation. 

Aids  to  Rapid  Dilatation.  —  There  are  many  uteri  which  are  difficult 
to  dilate  sufficiently  to  admit  the  finger,  and  it  is  impossible  to  decide 
beforehand  which  cases  will  prove  so  resistant.  It  used  to  be  said  that 
if  it  were  impossible  to  dilate  a  cervix,  this  was  a  fair  proof  that  it  was 
affected  by  malignant  disease.  As  a  rule  a  cervix  is  only  materially 
resistant  if  there  be  an  intramural  fibroid  involving  part  of  its  circumfer- 
ence, and  also  in  some  nulliparous  woirien,  but  only  twice  in  my  experi- 
ence has  this  been  sufficient  to  prevent  digital  exploration.  There  are  aids 
to  dilatation,  rendering  it  easier,  quicker,  and  less  dangerous,  which  it  is 
desirable  to  emphasise  ;  for  it  is  rare  to  find  that  anything  has  been  done 
to  prepare  the  patient  before  the  actual  operation,  except  perhaps  from 
the  antiseptic  point  of  view.  First  of  all,  it  is  infinitely  easier  to  dilate 
a  cervix  if  the  day  following  the  cessation  of  a  period  is  chosen.  The 
tissues  are  softer,  and  the  cervix  is  somewhat  patent.     Tliis  was  first 


GYNAECOLOGICAL    THERAPEUTICS  281 

noted  by  Dr.  C.  H.  F.  Kouth  in  1864 ;  recently  Dr.  Braithwaite  has 
drawn  special  attention  to  this  fact,  and  Dr.  Herman  has  shown  that 
this  relaxation  is  most  marked  on  the  third  and  fourth  days  of  ordi- 
nary periods ;  but  it  is  better  to  await  the  cessation  of  the  period 
before  attempting  dilatation.  Secondly,  the  cervical  glands  should  be 
encouraged  to  secrete,  for,  as  Dr.  Champneys  has  said,  dilatation  is 
physiological,  and  the  cervix  has  to  be  induced  to  yield.  When  it  yields 
it  also  secretes,  as  in  pregnancy  and  labour.  When  the  cervix  is  moist  it 
is  dilatable ;  when  dry  it  is  rigid ;  and,  in  this  latter  condition,  any 
attempt  at  rapid  dilatation  is  generally  a  failure,  and  might  cause  exten- 
sive tearing.  Many  writers  consider  the  best  way  to  overcome  this  rigid- 
ity is  by  preliminary  partial  dilatation  by  tents ;  but  it  is  evident  that 
there  may  be  danger  in  this  also,  as  well  as  several  hours'  discomfort  to 
the  patient. 

The  cervix  can  be  induced  to  secrete  freely  by  inserting  into  the 
vagina,  two  or  three  hours  before  the  operation,  a  wool  tampon  soaked  in 
glycerine,  or  less  effectually  by  a  gelatine  and  glycerine  pessary.  The 
effect  of  the  glycerine  is  enhanced  by  the  addition  of  a  little  cocaine, 
which  serves  to  relax  local  spasm,  as  it  does  in  rigid  cervix  in  the  first 
stage  of  labour.  In  either  case  the  glycerine  should  be  applied  close  up 
to  the  external  os  uteri.  Secretion  is  further  helped  by  giving  a  warm 
vaginal  douche  of  borax  or  creolin  solution  before  introducing  the  gly- 
cerine tampon. 

If  unusual  difficulty  be  anticipated,  owing  to  nulliparity,  advanced  age, 
or  the  presence  of  fibroids,  additional  help  is  afforded  by  passing  into  the 
cervical  cavity,  and  if  possible  through  the  os  internum,  some  gauze 
saturated  with  glycerine  and  iodoform.  This  may  be  introduced  from  six 
to  twelve  hours  before  the  operation,  which  it  greatly  facilitates  by  relax- 
ing the  musciilar  fibres,  and  partly  dilating  the  canal.  As  has  been 
stated  this  preliminary  gauze  packing  should  not  be  adopted  when  there 
is  an  offensive  discharge.  These  "  aids  "  practically  obviate  the  need  for 
a  preliminary  dilatation  by  tents  in  all  but  very  exceptional  cases. 

Methods  of  Rapid  Dilatation.  — Assuming,  however,  that  rapid  dilata- 
tion has  been  decided  upon  for  the  purpose  of  making  a  diagnosis  of  the 
intra-uterine  condition  to  which  is  due  the  hemorrhagic,  piirulent,  and 
possibly  offensive  discharge,  there  are  several  ways  by  which  this  can  be 
effected,  namely :  i.  By  graduated  bougies ;  ii.  By  two,  three,  or  four 
bladed  dilators  with  or  without  attached  screws ;  iii.  By  miscellaneous 
instruments. 

a.  Rapid  Dilatation  by  Graduated  Bougies.  — In  England  dilatation  by 
bougies  is  preferred ;  and  when  carefully  and  antiseptically  conducted,  it 
is  free  from  risk,  sufficiently  speedy  in  its  performance,  and  effectual  in  its 
results.  Hegar's  bougies  were  first  introduced  to  the  profession  in  1881, 
but  were  not  in  general  iise  in  this  country  till  eight  or  ten  years  later ; 
when  amongst  others  Drs.  Lewers  and  Phillips  drew  special  atten- 
tion to  their  value.  Hegar's  original  dilators  were  rather  short,  and 
niade  of  polished  wood  or  ebony  ;  they  consequently  gave  rise  to  a  good 


282 


SYSTEM  OF  GYNECOLOGY 


deal  of  friction,  and  were  if  anything  too  sharply  pointed.  To  overcome 
these  disadvantages  Hegar's  dilators  (Fig.  TO)  are  now  made  longer,  and 

the  metallic  bougies  now 
used  are  often  made  about 
the  same  length  as  a  male 
catheter,  with  a  sharper 
curve  than  Hegar's,  and 
are  constructed  of  hollow 
metal  tubes,  with  ends 
somewhat  less  pointed. 

There  are  numerous  va- 
rieties of  metallic  bovigies. 

Fig.  76.  -  Uterine  dilator  (Hegar's  improved).  ^^,'^^1^  varied  details   in  the 

length,  the  shape  of  the  point,  the  curve,  the  weight,  and  the  handle. 
Among  these  may  be  mentioned  those  of  Matthews  Duncan,  Galabin, 
Macnaughton  Jones,  Heywood  Smith,  Peaslee,  Godson,  John  Phillips, 
and  Hayes.  Those  of  the  last  type  (Fig.  77)  and  Matthews  Duncan's 
(Fig.  78)  are  probably  the  best. 

The  best  size  to  begin  with  is  one  Avith  a  diameter  of  four  milli- 


KROH  N E    &  C5     LON  D 0 N  )25 


KROHNE     a..     C°       LONDON 


Fig.  77.  —  Uterine  dilators  (Hayes'). 

metres,  and  each  succeeding  size  should  vary  in  diameter  not  more  than 
one  millimetre.  These  bougies  should  be  numbered  according  to  their 
diameters.  A  case  is  occasionally  met  with  where  one  millimetre  seems 
too  large  a  difference;  and  it  is  therefore  advisable  for  hospital  use  to 
have  some  made  with  half  a  millimetre  difference.  In  private,  the  diffi- 
culty is  overcome  by  giving  more  time,  or  by  having  always  in  the  bag 


"     •      «ON. 

Fio.  7S.  • —  Uterine  dilator  (Mattliews  Uiinean's). 

a  Goodell's  two-ljladed  parallel  dilator  (Fig.  83),  which  will  speedily  over- 
come the  resistance,  so  that  the  next  sized  bougie  may  be  used.  Such 
metal  bougies  as  these  involve  very  little  friction,  follow  the  jxdvic  and 
uterine  curve  easier,  and,  owing  to  their  greater  length,  allow  greater 
facility  of  manipulation.  Their  points  being  less  tapering  they  alsodilate 
the  uterus  right  up  to  the  fundus. 

With  these  bougies,  and  with  accelerants  to  dilatation  as  suggested, 
the  usual  time  taken  to  dilate  the  uterus  so  as  to  admit  the  finger  is 
about  fifteen  or  twenty  minutes.     Thus  I  myself  dilated  and  digitally 


G  YNMCOL  OGICAL    T HER  APE  UTICS 


283 


explored  the  uterus  in  two  patients  for  hgemorrhage ;  curetted  both  for 
fungous  endometritis ;  dilated  another  uterus  for  dy  smenorrhoea,  all  under 
ether ;  and  performed  another  small  operation  under  gas,  in  exactly  sixty 
minutes,  without  unusual  haste. 

The  Operation.  —  The  patient  having  been  duly  prepared  by  previous 
purgation,  the  vagina  having  been  douched,  and  all  antiseptic  precautions 
having  been  taken  as  already  described,  the  patient  is  anaesthetised,  with 
ether  for  choice,  and  is  placed  either  in  the  lithotomy  position  —  Clover's 
crutch  (Fig.  79)  being  employed  to  keep  the  legs  up  —  or  else,  as  some 
prefer,  in  the  Sims'  position. 


Fig.  79.  —Clover's  crutch. 


The  vagina  is  then  again  cleansed  with  a  1  in  2000  sublimate  solution, 
and  the  operator's  hands  and  the  instruments  being  prepared  as  stated, 
the  anterior  lip  (the  uterus  being  assumed  to  be  anteverted)  is  seized  with 
a  volsella  forceps,  drawn  downwards,  and  held  steady.  This  straightens 
the  uterine  curve,  and  prevents  the  strain  on  the  ligaments  which  must 
occur  if  the  bougies  are  i)assed  Avithout  the  uterus  being  thus  fixed.  A 
uterine  sound  is  next  introduced  to  ascertain  the  exact  curve  of  the 
uterine  cavity  when  thus  drawn  down ;  and  then  the  smallest  sized  bougie 
is  steadily  passed,  so  that  it  may  not  be  jerked  through  the  internal  os 
uteri  as  its  spasm  passes  off,  and  perhaps  made  to  impinge  roughly 
against  the  fundus. 

Some  recommend  that  the  operator  should  hold  the  volsella  forceps 
whilst  passing  in  the  bougie  so  as  to  estimate  the  amount  of  force  being 
used,  but  this  is  not  advisable.     An  assistant  should  hold  the  cervix 


2S4  SYSJ^EM   OF  GYNAECOLOGY 

immovably,  and  the  operator  should  then  pass  up  two  j&ngers  (a  speculum 
should  not  as  a  rule  be  used)  to  the  cervix,  and  introduce  the  bougie  along 
them ;  with  some  experience,  the  operator  can  estimate  very  accurately 
how  much  force  he  is  employing.  It  is  important  to  use  a  volsella 
forceps  which  will  not  readily  tear  or  cut  its  way  out,  and  for  this  reason 
Teale's  forceps  (Fig.  80),  which  has  several  blunt  teeth  on  each  face,  is  the 
best,  as  it  seizes  the  anterior  lip  bodily,  and  if  the  racket  on  its  handle 
is  efficient  it  practically  never  slips  off. 

The  time  which  should  elapse  between  the  passage  of  succeeding 
bougies  varies  greatly.  If  a  bougie  has  been  introduced  with  difficulty, 
time  should  be  allowed  for  it  to  get  loose  by  relaxation  of  the  cer- 
vical fibres ;  this  can  be  tested  by  partially  withdrawing  it  and 
feeling  whether  it  has  become  looser  in  the  grip  of  the  os  internum. 
Perhaps  one  to  three  minutes  may  be  needed  for  this  relaxation  to  occur, 
but  as  a  rule  a  few  seconds  suffice.     An  assistant  should  remove  the 


Teale's  forceps. 


bougies,  when  the  operator  has  ascertained  that  they  are  ready  for 
removal,  and  should  dip  them  in  warm  carbolic  solution  in  case  the 
operator  should  find  that  the  next  size  will  not  enter,  and  the  previous 
size  be  again  required.  By  allowing  an  assistant  to  remove  each  bougie, 
the  operator  is  enabled  to  have  in  his  hand  the  next  sized  bougie,  ready, 
warmed  and  oiled,  for  immediate  insertion.  This  is  an  important  detail, 
as  the  spasmodic  contraction  of  the  cervix,  even  under  dee^j  anoesthesia, 
is  remarkably  persistent,  the  pelvic  reflexes  not  being  annulled  till  after 
the  conjunctival  reflexes  are  quite  absent. 

The  extent  of  the  dilatation  required  will  vary  according  to  the  nature 
of  the  case.  If  a  digital  exploration  be  required,  it  is  usually  sufficient  to 
dilate  so  as  to  admit  the  little  finger,  especially  if  the  cervix  can  be 
drawn  well  down.  This  will  enable  the  operator  to  diagnose  a  polypus, 
UTaligiiant  disease,  or  fungous  endometritis  ;  but  he  must  not  be  satisfied 
till  he  has  succeeded  in  feeling,  if  possible,  the  whole  of  the  endometrium, 
including  the  two  cornua,  which  are  favourite  spots  for  placental  polypi 
and  hypertrophic  endometritis.  Tlie  finger  can  explore  uteri  which  are 
considerably  longer  than  the  examining  finger  if  the  other  hand  be  used 
to  press  down  the  fundus  from  over  the  pubes ;  care  being  taken  that  the 


GVNMCOLOGICAL    THERAPEUTICS  2S5 

bladder  is  empty.  If  malignant  disease  be  diagnosed,  no  further  dilatation 
is  required,  hysterectomy  being  needed  if  otherwise  indicated;  or  if  the 
diagnosis  be  uncertain,  the  curette  or  scissors  will  be  wanted  to  remove 
a  piece  for  microscopical  examination.  If  a  fibroid  polypus  be  found, 
further  dilatation  may  be  needed  to  admit  the  scissors,  forceps,  or  wire 
ecraseur  along  the  finger.  If  fungous  endometritis  be  detected  a  curette 
can  be  at  once  used.  If  a  bit  of  placenta  be  found,  it  may  usually  be 
detached  by  the  finger  tip. 

Sometimes  the  diagnosis  of  fungous  endometritis  is  made  after  the 
passage  of  a  few  bougies,  by  pieces  of  characteristic  material  coming  away; 
but  it  is  only  safe  to  accept  this  as  the  sole  condition  in  small  uteri,  as 
it  is  not  unusual  to  find  this  state  of  the  endometrium  complicating 
both  submucous  fibroid  and  polypus. 

It  is  evident  that  the  amount  of  dilatation  for  exploratory  pur- 
poses really  depends  upon  the  size  of  the  operator's  little  finger,  or 
rather  upon  the  size  of  the  second  joint  of  that  digit ;  and  this  is  a  matter 
of  considerable  moment,  as  fingers  vary  several  millimetres  in  diameter. 


Fig.  81.  — Budin's  tube. 


and  any  risk  to  the  patient  is  necessarily  proportional  to  the  amount  of 
dilatation  required.  It  is  for  this  reason  that  diagnosis  should  be  made 
by  the  little  finger,  and  not,  in  cases  of  rigid  cervix  at  all  events,  by  the 
index  finger.  Usually  the  fingers  of  the  left  hand  are  smaller  than 
those  of  the  right. 

Whatever  be  the  object  of  the  dilatation,  and  Avhatever  be  the  subse- 
quent procedure  (curetting,  removal  of  polypus,  etc.),  it  is  advisable  to 
apply  to  the  endometrium  some  strong  antiseptic  counter-irritant,  such 
as  iodine  liniment  or  iodised  phenol,  on  a  Playfair's  probe,  which  should 
be  covered  with  as  much  wool  as  will  easily  enter  the  dilated  cervix. 

To  permit  free  drainage,  and  to  prevent  uterine  colic  following  the 
application  of  the  iodine,  a  piece  of  iodoform  gauze  should  be  passed  up 
to  the  fundus  in  the  manner  previously  described,  and  should  not  be 
removed  till  next  morning  when  the  vagina  will  also  be  douched. 

Some  operators  prefer  not  to  apply  any  antiseptic  after  dilatation, 
unless  purulent  endometritis  is  present,  or  the  discharge  indicates  the 
existence  of  a  septic  intra-nterine  condition.  It  is  advisable,  however,  if 
this  be  not  done,  and  if  a  flushing  curette  be  not  subsequently  used,  to 
wash  out  the  uterus  thoroughly  Avith  iodised  or  carbolised  water  at  a 
temperature  of  about  118°  F.,  by  means  of  a  double-channelled  tube  of 


286 


SYSTEM  OF  GYNECOLOGY 


glass  or  celluloid,  such,  as  Budin's  (Fig.  81),  or  Graily  Hewitt's  glass 
tube  (Fig.  82),  or  a  metallic  one,  such  as  Bozeman-Fritsch's. 

The  Dangers  of  Eapid  Dilatation.  —  The  risk  of  rapid  dilatation  is  very 
small  if  carried  out  thus.  There  is  hardly  ever  any  subsequent  pyrexia ; 
if  there  be,  it  is  almost  always  in  cases  where  malignant  disease  has 


Fig.  S'2.  — Graily  Hewitt's  uterine  tube. 

been  diagnosed,  and  then  probably  arises  from  septic  absorption.  In 
cases  of  tubal  disease  there  is  sometimes  a  little  inflammatory  reaction ; 
but  if  free  drainage  be  provided  this  soon  passes  off,  and  any  chronic 
salpingitis,  which  existed  as  a  sequence  to  the  concurrent  endometritis, 
often  disappears  within  a  few  Aveeks  (C.  H.  F.  Routh,  Doleris,  Trelat). 
"  Lumps  in  the  pelvis,"  such  as  are  due  to  ovarian  congestion  or  swollen 
tubes,  are  not  necessarily  contra-indications  to  rapid  dilatation,  for  slow 
dilatation  by  tents  would  be  more  risky  (see  curetting). 

If  by  some  accident  —  such  as  roughness  on  the  part  of  the  operator 
or,  as  more  often  happens,  in  extreme  softness  of  the  uterine  tissues, 
as  in  some  cases  of  subinvolution,  or  where  the  tissues  are  friable  as 
in  carcinoma  —  perforation  of  the  uterus  has  occurred,  serious  results 
may  not  follow,  provided  that  antisepsis  has  been  thorough,  and 
recognition  of  the  accident  immediate.  The  proper  treatment  in  such 
cases  is  to  cease  further  dilatation,  and  after  cleansing  the  vagina  and 
endocervix,  lightly  to  pack  the  uterine  cavity  with  gauze.  In  a  few 
hours  lymph  will  have  covered  over  the  perforation,  and  probably  no 
symptoms  beyond  some  sickness  will  ensue.  All  cases  of  perfoi-ation  do 
not  teniiinate  thus  satisfactorily,  but  these  are  either  in  themselves  septic, 
or  antiseptics  have  been  neglected ;  or  the  accident  has  not  been  recognised, 
and  more  bougies  have  been  passed,  possibly  even  a  curette  used,  and  the 
bowel  injured.  Fortunately  such  accidents  are  very  rare,  but  the  possi- 
bility of  the  uterine  tissue  being  extremely  soft  must  be  kept  in  mind. 
If  it  be  realised  that  the  perforation  through  the  uterus  is  extensive,  or 
the  uterine  contents  septic,  or  that  the  bowel  have  come  down  into 
the  uterin''^-  cavity,  the  abdomen  may  be  opened ;  and  if  the  rent  cannot 
be  suture  1  hysterectomy  should  be  performed:  some  operators  would 
at  once  proceed  to  perform  vaginal  hysterectomy,  being  particularly 
careful  to  ensure  subsequent  good  drainage  by  gauze. 

If  the  cervix  be  rigid,  slight  lacerations  of  the  mucous  membrane 
usually  ocrair,  a.nd  occasionally  wlien  the  exploring  finger  is  introduced 
ratlier  deep  splits  are  found,  usually  on  the  left  side;  but  in  a  series  of 
several  Innidred  cases  \  have  never  seen  perrna,nent  mischief  result,  or 
even  inflammatory  troubles  follow.     Such  tears  seem  to  commence  at  the 


G  YNM  COLO  GICAL    T HER  APE  UTICS 


287 


level  of  the  os  internum,  and  may  be  suspected  if  a  bougie  pass  easily- 
after  the  preceding  smaller  size  entered  with  difficulty. 

Occasionally  haemorrhage  suddenly  arises  during  a  dilatation,  as  for 
instance  when  a  piece  of  placental  polypus  becomes  detached,  appearing, 
it  may  be,  at  the  os  externum  when  the  bougie  is  withdrawn.  In  such 
a  case  the  haemorrhage  is  sometimes  alarming,  and  time  cannot  be  wasted 
by  attempting  further  dilatation  with  a  view  to  explore  with  the  linger 
—  though  it  may  be  worth  while  to  pass  in  the  curette  and  rapidly  scrape 
the  endometrium  to  remove  any  more  placental  tissue,  and  thus  encourage 
retraction  :  but  if  the  haemorrhage  persist,  as  it  probably  will,  the  uterus 
should  be  plugged  at  once  with  antiseptic  gauze,  and  the  plugs  retained 
in  utero  for  twenty-four  hours,  by  which  time  the  uterus  will  be  sufficiently 
dilated  to  admit  the  finger  if  necessary.     The  haemorrhage  apj^ears  to  be 


Fig.  83.  —  Goodell's  two  parallel-bladed  dilator. 


arrested  by  pressure  and  by  the  blood  coagulating  readily  upon  the  gauze 
fibres,  and  not,  at  all  events,  solely  by  the  uterus  being  excited  to  con- 
tract by  the  presence  of  a  foreign  body :  for  it  is  evident  that  even  if 
(contraction  and  retraction  of  the  muscles  at  the  site  of  the  haemorrhage 
be  the  immediate  effect  of  the  gauze-packing,  a  secondarj'  effect  is  a 
further  passive  dilatation  and  relaxation,  and  yet  haemorrhage  does  not 
then  recur. 

|8.  Kapid  Dilatation  by  Two  and  Three  Bladod  Dilators.  — There  are 
some  who  prefer  this  type  of  dilator,  but  none  of  these  instruments  has 
met  with  universal  approval,  owing  to  the  irregular  way  in  whicli  they 
dilate,  the  time  occupied  by  the  process,  the  more  frequent  failure,  and 
the  greater  tendency  to  tearing  of  the  cervix.  There  is,  however,  a  great 
advantage  in  having  one  of  these  instruments  at  hand  when  dilating  with 
bougies,  as  it  occasionally  happens  that  the  operator  finds  it  difficult  to 
pass  the  next  sized  bougie,  or  possibly  a  particular  bougie  may  have  been 
forgotten.    The  possession  of  a  dilator  of  this  type,  like  Goodell's,  is  then 


288 


SYSTEAf  OF  GYNECOLOGY 


most  opportune,  and  its  employment  Avill  enable  the  further  dilatation 
to  be  made  with  the  other  bougies. 

The  preliminary  steps  are  identical  with  those  required  for  dilatation 
by  bougies,  both  as  regards  antiseptics,  ausesthesia,  and  the  position  of 


Fig.  84.  —  Uterine  dilator  (Ellinger's). 


the  patient.  The  cervix  must  also  be  seized  and  steadied,  and  the  uterus 
drawn  down ;  it  is  advisable  to  use  a  duckbill  speculum,  so  as  to  introduce 
and  screw  up  the  dilator  by  the  aid  of  inspection.  The  best  instruments 
are  Goodell's  (Fig.  83)  or  Ellinger's  two-bladed  dilators  (Fig.  84),  or 
Sims'  three-bladed  dilator  (Fig.  85).  The  two  former  are  the  best,  as 
they  dilate  by  parallel  blades. 


(■<\ 


K--y' 


Fig.  85.  —  Sims'  three-bladed  dilator. 


For  the  employment  of  all  these  instruments  the  cervix  should  be 
somewhat  patent ;  and  if  it  be  found  that  they  cannot  enter  the  cervix 
above  the  os  internum,  a  smaller  sized  dilator,  such  as  Palmer's  two-bladed 
dilator  (Fig.  8G),  should  be  first  used,  or  a  few  bougies  passed.  The  most 
important  precaution  in  dilating  by  these  instruments  is  to  avoid  screw- 
ing up  the  blades  in  one  diameter  of  the  cervix  only.  They  should  be 
opened  very  gradually  in  the  transverse  diameter  fii'st,  then  unscrewed 
and  rotated,  and  again  opened  in  another  diameter,  and  so  on  till  disten- 
sion of  the  muscle  fibres  has  been  uniforinly  effected  all  round.  In  a 
soft,  relaxed  cervix  dilatation  can  be  easily  (iffecjted  by  this  means ;  but 
in  the  nulliparous  rigid  cervix  complete  dilatation  is  often  impossible, 
or  if  possible,  open  to  serious  risk. 

In  cases  of  dysmenorrhnea,  where  moderate  stretching  is  to  bo  effected 
as  a  method  of  treatment,  dilatation  by  these  instruments  is  fairly  satis- 
factory; and  if  it  lie  desired  to  attem])t  a  ])artial  dibitation  without 
anaisthesia,  a  small-bladed  instrument  like  Talmer's,  Priestley's  (Fig.  87), 


G  VN^E  COLO  GICAL    T HER  APE  UlICS 


or  Collins'  may  be  passed  in,  and  a  few  turns  given  to  the  screw.  Some- 
times great  improvement  follows  as  regards  the  pain  and  sickness  usually 
accompanying  the  period,  which  should  not  be  more  than  two  or  three 


'^=-:-> 


'/2.  SCALE 

Fici.  SC.  —  Palmer's  two-bladoil  dilator. 


Fig.  87. —Dilator 

^rriestloy'.-l. 


Fig.  SS.  —  Uterine  dilators 
(Ueid's). 


days  distant.  The  danger  of  such  a  partial  proceeding  is  that  there  is  a 
risk  of  neglecting  complete  antisepsis,  and  serious  inflammation  might 
then  follow.     There  are  many  instruments  on  the  same  principle,  such  as 

u 


290  SYSTEM  OF  GYNAECOLOGY 

Gardner's,  "Wathen's,  Buck's,  Simpson's,  Pearson's.  Some  of  these  are 
■worked  b\'  hand-pressure,  some  by  screws. 

y.  Rapid  Dilatation  by  Miscellaneous  Instruments. — Such  instru- 
ments are  numerous.  A  few  will  suffice  as  types.  Dr.  Reid  of  Glasgow 
has  invented  a  conical  screw  dilator,  with  dift'erent-sized  screws.  They 
answer  well  in  the  inventor's  hands,  or  when  his  instructions  are  fol- 
lowed ;  but  his  method  is  not  satisfactory  in  cases  of  rigid  or  indurated 
cervix,  as  unless  the  tissues  yield  readily  the  biting  of  the  conical  screws 
causes  abrasion  of  the  lining  membrane.  Mr.  LawsonTait,  again,  has  some 
conical  dilators,  which  are,  however,  only  "  rapid  "  when  compared  with 
tents,  for  two  or  three  hours  at  least  are  required  for  each  sized  conical 
wedge  to  do  its  work.  They  are  cones  fixed  to  a  vaginal  stem  or  holder 
attached  to  elastic  bands,  which  pass  up,  two  in  front  and  two  behind,  to 
be  fastened  to  a  belt  or  waistband.  By  regulating  the  tension  of  these 
bands  the  direction  and  amount  of  pressure  can  be  arranged;  but  inasmuch 
as  these  details  require  careful  watching  and  readjustment,  the  method 
is  only  suitable  for  hospital  work,  and  it  is  clearly  capable  of  causing 
dangerous  upward  pressure  if  by  any  accident  the  bands  are  not  loosened 
when  the  dilatation  of  the  cervix  is  completed.  Fritsch  has  also  in- 
vented some  conical  dilators,  to  be  used  manually  just  as  the  graduated 
bougies  are  used. 

More  ^Madden's  dilator  is  two-bladed,  but  instead  of  dilating  equally 
along  the  cervix,  it  dilates  from  its  upper  end,  where  the  ends  most 
diverge ;  so  that  the  uterus  is  dilated  first,  then  the  os  internum,  and 
gradually,  as  the  instrument  is  drawn  out,  the  endocervical  canal  becomes 
stretched.  It  is  no  improvement  upon  such  instruments  as  Goodell's 
two-bladed  dilator. 

Duke's  two-bladed  dilator  has  a  more  decided  curve,  and  its  blades, 
which  open  by  a  powerful  screw,  are  conical  in  shape. 

lleverdin  uses  a  two-bladed  dilator  with  one  blade  hollowed  out  for 
flushing,  and  he  states  that  dilatation  is  accelerated  by  the  continuous 
flow  of  a  warm  antiseptic  solution. 

C.  Combined  Gradual  and  Rapid  Dilatation.  —  After  failing  to  dilate 
the  cervix  to  the  "exploratory  "  size  by  rapid  dilatation,  it  is  not  safe  to 
continue  the  dilatation  with  tents  until  the  abrasions  have  healed.  The 
mucous  membrane  is  necessarily  torn  here  and  there  after  such  a  trial, 
and  septic  absorption  is  very  prone  to  occur.  In  such  a  case  the  best 
plan  is  to  antisepticise  the  endometrium  thoroughly,  and  then  to  pack 
the  cavity  gently  but  firmly  with  10  per  cent  iodoform  gauze,  as  before 
described.  This  will  efficiently  dilate  the  uterus  in  twenty-four  hours 
witliout  any  appreciable  risk. 

Previous  to  rapid  dilatation  in  nulli])ar()iis  women,  it  is  tlio  routine 
custom  of  some  o|)Oi'atoi-s  to  dilate  the  cervix  pii.rtially  overniglit  l)y  means 
of  tents,  prefei-al)ly  laininaria.  Tliis  undouljtedly  scjf'teus,  and  begins  to 
dilate  the  cervix,  V>ut  is  rarely  necessary,  as  it  usually  gives  the  patient 
a  very  uncomfortable  night;  and  if  the  aids  to  rapid  dilatation  described 
on  page  280  be  made  use  of,  this  preliminary  dilatation  can  be  dispensed 


GYNECOLOGICAL    THERAPEUTICS  291 

with,  01-  accomplished  much  more  safely,  with  far  less  discomfort  and 
quite  as  effectually,  by  stuffing  the  endocervix  with  gauze,  as  described 
on  page  274. 

D.  Dilatation  with  Incision.  —  Occasionally  the  os  uteri  externum 
remains  rigid,  while  the  rest  of  the  cervix  has  become  relaxed  and 
dilatable ;  it  may  then  become  necessary  to  divide  the  rigid  rim  bilater- 
ally. A  common  instance  of  this  is  where  an  intra-uterine  polypus  has 
been  partly  extruded,  and  has  fully  dilated  the  whole  cervix,  except  a 
rim  of  rigid  tissue  at  the  os  externum.  Here  a  slight  notch  on  each  side, 
the  loss  of  a  little  blood,  and  the  yielding  of  the  rigidity,  will  afford  suffi- 
cient space,  and  dilatation  can  then  be  proceeded  with. 

Incisions  for  this  purpose,  and  for  the  division  of  the  os  externum  in 
cases  of  pinhole  os  and  conical  cervix,  may  need  to  be  somewhat  more 
than  mere  notches.     Then  Kiichenmeister's  scissors  (Fig.  89)  should  be 


Fig.  89.  —  Scissors,  uterine  (Kachenineister's). 


used  instead  of  ordinary  scissors  or  bistouries.  Kiichenmeister's  scissors 
have  a  probe-pointed  blade  which  is  passed  into  the  cervical  canal,  and  a 
hooked  blade  Avhich  grips  the  cervix  on  its  vaginal  aspect  and  prevents 
its  slipping,  and  so  dispenses  with  the  \ise  of  sharp  hook  or  volsella 
forceps.  The  extent  of  the  desired  incision  is  regulated  by  the  distance 
of  the  hooked  blade  from  the  external  os  uteri,  as  this  blade  is  the 
cutting  one. 

In  all  cases  where  a  mere  temporary  dilatation  is  needed,  the  incision 
should  be  sewn  up  at  once  with  wire  or  silk-worm  gut,  lest  ectropion  and 
chronic  endocervicitis  may  ensue. 

Incision  by  means  of  a  Paquelin's  cautery,  or  the  galvanic  cautery  with 
the  platinum  terminals  brought  to  a  dull  red  heat,  is  very  efficacious  in 
preventing  haemorrhage;  and  it  may  advantageously  be  used  when  it  is 
desired  to  prevent  rapid  reunion  of  the  incised  cervix,  as,  for  instance, 
when  the  os  uteri  externum  has  been  divided  for  "pinhole  os.''  The 
cautery,  however,  should  never  be  used  to  incise  the  internal  os  uteri  or 
the  cervix  high  up,  where  the  In-anches  of  the  uterine  artery  may  be 
found,  as,  even  if  it  prevent  luBinorrhage  at  tlie  time,  secondary  luemor- 
rhage  is  very  likely  to  occur ;  and  owing  to  the  necessary  sloughing, 
perfect  asepsis  at  that  level  is  very  difficult  to  maintain.  If  it  is  desired 
to  prevent  closure  of  the  incision,  and  the  cautery  has  not  been  employed, 


SYSTEM  OF  GYNECOLOGY 


the  raw  surfaces  sliould  be  touclied  with  iodine  liniment ;  and  a  piece  of 
gauze,  soaked  in  iodised  gl^-cerine,  should  be  kept  in  the  cervix  for  some 
days,  beyond  the  upper  limit  of  the  cut,  being  changed  of  course  daily, 
and  a  vaginal  douche  given  at  the  intervals. 

If  haemorrhage  be  severe,  it  may  usually  be  arrested  by  plugging  the 
cervical  cavity  with  gauze ;  or  the  bleeding  point  may  be  touched  Avith  the 
actual  cautery,  though,  as  has  just  been  stated,  this  has  its  disadvantages. 
If  this  do  not  arrest  the  bleeding,  the  uterine  artery,  or  the  branch  going 
to  the  cervix,  must  be  tied. 

In  those  very  rare  cases  where,  owing  to  the  failure  of  a  rapid  dilata- 
tion, hj'sterotomy  to  the  level  of  the  os  internum  has  been  decided  upon, 
it  has  been  very  strongly  recommended  by  such  authorities  as  Schroeder, 
ZVIartin,  and  Pozzi  that  the  uterine  artery,  or  rather  the  large  branch 
which  enters  the  cervix  at  the  base  of  the  broad  ligament,  should  be  tied. 
This  can  be  done  by  a  curved  needle,  Avhich  should  be  entered  precisely 
as  when  the  artery  is  tied  for  vaginal  hysterectomy,  except  that  there  is 
no  need  to  divide  any  mucous  membrane  before  passing  the  needle.  After 
reuniting  the  incisions  in  the  cervix,  or  at  all  events  after  the  lapse  of 
twelve  hours,  the  ligatures  should  be  removed  to  prevent  ulceration  of  the 
mucous  membrane  where  it  Avas  included  in  the  knot.  If  this  preliminary 
ligation  of  the  arteries  Avere  efficiently  performed,  the  greatest  danger  of 
the  operation,  that  of  death  from  primary  haemorrhage,  Avould  be  entirely 
obviated.  The  danger  from  sepsis  has,  of  course,  to  be  otherAvise  combated. 

After  such  an  "high"  operation  it  may  be  advisable  to  introduce  a 
stem  pessary,  such  as  MeadoAvs'  glass  stem,  till  healing  is  completed. 
With  rest  in  bed  and  perfect  antisepsis  this  ensures  free  drainage.  For 
this  "high"  operation  Kiichenmeister's  scissors,  which  can  only  cut  to 
the  level  of  the  vaginal  vault,  are  not  suitable ;  for  the  cervix  need  not  be 
cut  through  from  its  cavity  into  the  vagina  except  at  the  os  externum. 
Practically  the  simplest  plan  is  to  dilate  the  cervix  partially,  and  then 
to  incise  the  neck  of  the  uterus  at  the  desired  level,  and  to  the  desired 
extent,  by  means  of  a  Sims'  knife  (Fig.  90)  set  at  a  suitable  angle,  or  by 


Kkj.  9(1.  — Sims'  metrotome. 


a  straight  probe-pointed  bistoury,  which  can  be  easily  introduced  if  the 
uterus  V)e  draAvn  down  by  a  volsella. 

Formerly  single  hysterotomes,  such  as  Simpson's  or  Priestley's,  were 
used,  but  they  have  no  advantage  over  a  probe-pointed  bistoury,  which  is 
far  safer  than  the  doultle  hysterotomes,  such  as  Grtuv-jilialgh's  and  its 
modifications  (Savage's  or  Peaslee's),  all  of  which  are  apt  to  cut  more 
dee};ly  on  the  side  Avhere  there  is  less  resistance,  and  have  been  the  cause 
of  most  of  the  disasters  to  Avhich  the  operation  has  led. 

ii.  Curetting  the  Uterus.  —  Curretting  was  introduced  by  llecamier  in 
1843,  and  was  so  vehemently  opposed  that  it  fell  immediately  into  dis- 


GYNECOLOGICAL    THERAPEUTICS  293 

repute,  though  in  1850  Eeeamier  was  still  advocating  his  curette  for  the 
"  removal  of  intra-uterine  fungosities,"  which  he  had  discovered  to  be 
often  the  cause  of  obstinate  metrorrhagia.  In  1846  Sir  Charles  Locock 
described  his  scoop  for  the  removal  of  malignant  nodules,  and  soon  after- 
wards Simon's  scoop  was  also  recommended.     In  1861  C.  H.  F.  Routh 


Fig.  91.  — Simon's  uterine  scoop. 

somewhat  modified  Eecamier's  curette,  and  read  a  paper  at  the  Obstetrical 
Society  of  London,  giving  three  cases  of  metrorrhagia  cured  by  its  use  after 
a  diagnosis  had  been  made  by  slow  dilatation  and  digital  exploration.  In 
1866  Sims  introduced  his  sharp  curette  with  a  malleable  handle.     This 


Fig.  92. — Sims'  pliable  curette. 

continued  to  be  the  favourite  curette  till  about  1874,  when  Thomas  intro- 
duced, and  Munde  strongly  advocated,  a  "  dull  curette  of  flexible  copper 
wire,"  and  this  was  used  almost  universally  in  America  for  some  years. 
In  the  same  year  Hegar,  Kaltenbach,  and  Olshausen  brought  its  use 
prominently  into  notice  in  Germany  ;  and  in  France,  Trousseau,  Xelaton 
(1861),  jNEaisonneuve,  and  Xonat  (1869)  had  occasionally  made  use  of  it. 
In  England  it  was  long  in  coming  into  favour,  for  in  spite  of  its  occasional 
use,  as  stated  above,  it  was  opposed  at  first  by  such  men  as  Barnes  and 
Atthill,  though  in  1873  the  former,  and  somewhat  later  the  latter,  advised 
its  use  in  serious  cases. 

With  such  well-known  gynsecologists  as  Courty  (1866),  Scanzoni 
(1861  to  1865),  Thomas  (up  to  1871),  Schroeder,  and  Colucci  (1877) 
writing  against  the  use  of  the  curette,  it  is  not  surprising  that  very 
little  progress  was  made;  and  in  spite  of  the  recommendation  of  many 
strong  advocates,  it  is  probable  that  it  would  never  have  become  so  uni- 
versally employed  as  it  is  now  if  the  era  of  antiseptics  and  of  anaesthetics 
had  not  made  it  both  safe  and  easy  of  execution. 

Indications  for  Curetting.  —  This  operation  may  be  used  merely  to 
make  a  diagnosis  of  the  state  of  the  endometrium,  b}^  scraping  off  a  small 
piece  of  the  mucosa  for  microscopic  examination.  For  such  a  piirpose 
a  small  exploratory  curette  can  be  used  A^thout  previous  dilatation. 
Curetting  is  done  both  for  hypertrophic  and  atrophic  endometritis.  It 
is  done  also  for  cases  of  septic  or  infective  endometritis,  with  their  resulting 
purulent  discharges,  in  order  to  prevent  sequential  tubal  and  periuterine 
complications  from  extension  of  the  inflammation.  Whether  the  process 
advance  through  the  tubes,  or  through  the  lymphatics  of  the  uterine 
tissues,  the  result  is  very  serious,  and  a  timely  curetting  may  prevent 
such  disaster. 


294  SYSTEM  OF  GYNECOLOGY 

Even  if  the  periuterine  tissues  be  already  involved,  it  is  good  practice 
to  remove  the  infective  focus  in  utero  by  an  efficient  curetting ;  and  if  it 
be  considered  necessary  to  open  the  abdomen  and  deal  with  some  serious 
condition  there  which  has  followed  the  endometritis,  it  is  right  to  curette 
the  uterus  beforehand  or  simultaneously.  In  many  cases  the  peri- 
uterine exudation,  Avhether  in  tubes  or  peritoneum  or  as  phlegmon  in 
the  cellular  tissue,  will  disappear  after  a  careful  curetting  and  packing  of 
the  uterus  with  gauze  to  ensure  free  drainage ;  and  unless  an  abdominal 
section  be  clearly  necessary,  this  minor  operation  should  be  first  tried. 
The  time  will  almost  surely  come  when  the  practice  will  be  to  curette 
the  uterus,  or  otherwise  cure  the  endometritis,  in  all  cases  of  tubal  or 
peritoneal  inflammation  of  uterine  origin,  in  which  there  is  no  abscess. 

Sometimes  an  endometritis  exists  with  haemorrhage  as  its  chief 
symptom.  This  is  usually  hypertrophic  and  adenomatous  in  nature.  For 
this  state  also  curetting  is  indicated. 

Curetting  is  also  needed  for  the  removal  of  placental  or  membranous 
debris  retained  after  labour  or  abortion.  Such  a  condition  is  almost  the 
only  indication  for  a  blunt  curette,  for  the  uterus  may  be  very  soft ;  but 
in  such  cases  the  cervix  is  generally  so  patent,  or  so  easily  dilated,  that 
the  insertion  of  the  finger  involves  no  difficulty,  and  the  piece  of  retained 
placenta  or  other  matter  can  almost  certainly  be  removed  by  the  finger- 
tip alone.  If,  however,  the  discharge  be  septic,  and  especially  if  general 
septicaemia  be  setting  in,  a  deep  and  thorough  curetting  of  the  whole 
endometrium  is  imperatively  necessary  if  the  patient's  life  is  to  be  saved. 

Varieties  of  Curettes.  —  Curettes  should  be  provided  with  some  ar- 
rangement of  the  handle  or  shaft  to  prevent  rotation,  and  to  enable  the 
operator  to  know  which  is  the  sharp  and  which  the  blunt  edge  of  the 
end.  Some  curettes  have  a  sharp  loop  at  one  end,  and  a  blunt  at 
the  other ;  and  as  these  loops  are  on  opposite  faces  of  the  shaft,  the 
outside  end  gives  sufficient  indication  of  the  direction  of  the  intra-uterine 
end.  Some  curettes  have  loops  of  different  sizes  or  curves  at  the .  two 
ends.     Amongst  such  are  Gervis'  (Fig.  93),  Eecamier's  (Fig.  94),  and 


«BN0LQa.S0NSLONDUN 

Fifj.  93.  —  Double  uterino  curette  (Gervis'). 


that  used  at  St.   Bartholomew's  Hospital.     The  first  is  sharp-edged, 
the  second  is  blunted :  all  are  excellent  instruments,  but  it  is  desirable 


z:^ 


Fkj.  94.  —  K6camier'B  curette. 


to  have  at  least  one  end  of  the  Hecamier's  curette  sharpened  for  deep 
curetting.  For  scraping  away  the  f  riaV)le  tissues  of  amalignant  growth — 
as  a  palliative  measure,  or  preparatory  to  a  radical  operation — Volkmann's 


G  YNM  COL  O  GICAL    THERAPE  UTICS 


295 


or  Thomas'  uterine  scoops  (Fig.  95)  are  better  than  ordinary  curettes. 
Bell's  dredging  curette  (Fig.  96)  is  also  very  useful  in  malignant  cases, 


ARNOLn&SCKSLOHDON 

Fig.  95.  —  Uterine  scoop,  or  spoon  saw  (Thomas'). 


especially  where  the  cervix  is  too  friable  to  be  grasped  with  the  vol- 
sella  forceps,  and  an  intra-uterine  diverging  tenaculum  has  to  be  used. 
In  such  a  case  Bell's  curette  will  clear  a  way  along  the  uterine  cavity, 
so  as  to  admit  the  tenaculum,  better  than  any  other  instrument.  It 
is  not  so  suitable  for  ordinary  curetting  unless  the  uterine  cavity  be 
normally  regular  in  outline ;  though  much  may  be  done,  by  outside  supra- 


**  il  a  i;l  I  'A 


Fiu.  90.  —  Dredging  curette  (Bell's). 


pubic  pressure,  to  bring  the  different  parts  of  the  endometrium  in  contact 
with  the  instrument,  Avhich  has  other  advantages,  and  can  be  constructed 
with  a  hollow  shaft  for  flushing  purposes.  Jessett's  watch-spring  dredg- 
ing curette  is  more  dangerous,  but  is  otherwise  on  the  same  lines.  Both 
these  instruments  leave  too  much  to  chance,  and  most  operators  would 
therefore  prefer  an  ordinary  looped  curette,  which  is  more  generally 
useful. 

Flushing  curettes  —  that  is,  curettes  with  the  shaft  hollowed  out  from 
the  end  of  the  handle  to  the  space  within  the  loop  of  the  scraping  end  — 
are  very  useful,  and  may  be  made  like  Duke's,  with  the  shaft  only  partly 


Fig.  97.  —  Uterine  flushing  curette  (Auvard's). 


hollowed ;  or  like  Auvard's  (Fig.  97),  with  a  place  on  the  shaft  in  which 
to  dip  the  pulp  of  the  index  linger  to  secure  steadiness  ;  or  like  llouth's 


Fic.  98.  —  Kouth's  flushing  curette. 


(Fig.  98),  which  is  longer  in  the  shaft,  has  the  tubing  attached  to  the 
extreme  end  of  the  handle,  and,  half-way  along  the  shaft,  has  a  flat  plate 


296  SVSTEM   OF  GYNECOLOGY 

to  lie  in  the  palm  of  the  hand  to  steady  the  instrument  and  prevent 
rotation. 

Tlie  Operation  of  Curetting.  —  It  may  be  assumed  that  dilatation  has 
been  performed,  that  sufficient  exploration  of  the  uterus,  by  sound,  ex- 
ploratory scraping,  or  insertion  of  the  finger,  has  been  made,  and  that 
curetting  is  indicated. 

The  patient  should  be  in  the  lithotomy  position,  both  to  facilitate  the 
operation  and  to  permit  a  perfect  irrigation.  The  cervix  is  steadied  and 
lowered  as  in  rapid  dilatation,  and  the  largest-sized  curette  which  will 
readily  enter  is  passed  up  to  the  fundus,  and  then  withdrawn  with  the 
sharp  edge  against  the  mucosa.  This  is  repeated  all  over  the  intra- 
uterine surface.  Special  care  is  taken  at  the  two  cornua,  as  clumps  of 
hypertrophic  tissue  are  apt  to  collect  there ;  to  get  at  them  it  may  be 
necessary  to  use  a  smaller  curette,  or  one  with  the  end  set  at  a  different 
angle.  The  cervix  also  should  be  subsequently  curetted.  In  curetting, 
pressure  with  the  sharp  end  should  be  firm  and  equal ;  and  in  going  over 
the  surface  again  to  make  sure  (if  possible)  that  all  of  the  mucosa  has 
been  removed,  it  will  be  noted  that  if  the  curette  cause  a  grating  feeling 
or  sound,  it  indicates  that  the  mucosa  has  already  been  removed ;  but 
if  no  such  sensation  is  produced,  the  lining  membrane  is  still  intact  at 
that  spot,  and  needs  further  attention. 

After  Treatment.  —  The  uterus  should  be  washed  out  with  an  antisep- 
tic douche  at  about  118°  F.,  if  no  flushing  curette  has  been  used ;  and 
then  its  rawed  surface  should  be  painted  freely  with  iodine  liniment, 
carried  up  through  a  speculum  on  a  probe  armed  with  plenty  of  wool. 
In  any  case  where  sceptic  or  infective  endometritis  exists,  the  uterus 
should  then  be  packed  with  iodoform  gauze  to  encourage  free  drainage ; 
if  further  intra-uterine  treatment  be  indicated,  the  gauze,  which  should 
be  removed  in  twelve  hours,  should  be  replaced,  and  the  uterus  kept  pat- 
ent. If  there  should  be  severe  ha3morrhage  this  packing  should  also  be 
resorted  to,  done  however  more  tightly,  with  a  firm  vaginal  tampon  below. 
In  this  latter  case  the  uterine  tampon  may  be  left  in  for  tAventy-four 
hours.  In  most  cases  antiseptic  douches  are  advisable  for  the  first  week, 
after  which  time  the  patient  may  get  up  and  may  resume  her  ordinary 
duties  in  a  fortnight. 

iii.  Alternatives  to  Curetting. — Excluding  serious  operation  like 
hysterectomy,  always  unjustifiable  in  cases  where  curetting  is  an 
alternative,  these  cases  of  endometritis  must  either  be  treated  pal- 
liatively  by  curetting  or  by  some  escharotic. 

Minor  palliative  methods  have  been  described  under  the  heads  of 
intra-uterine  medication,  and  dilatation  by  gauze-packing,  and  need  not 
here  be  again  referred  to,  except  to  say  that,  as  stated  on  page  276,  some 
of  the  mild  and  uncomplicated  cases  of  endometritis  will  yield  to  them. 

Troatinent  by  escharotics,  such  as  chloride  of  zinc,  nitric  acid,  or 
electricity  with  strong  currents,  involvfis  the  formation  of  extensive 
sloughs,  the  depth  of  whi(;h  cannot  be  regulated.  Such  a  slough  is  itself 
a  danger,  and,  as  the  surface  of  repair  which  is  left  has  very  little 


G  YNM COL  0 GICAL    THERAPE  UTICS 


297 


protective  epithelium  to  defend  it  against  the  passage  of  pathogenetic 
germs,  the  slough  is  thrown  off  by  suppuration,  and  an  atrophic  endo- 
metritis results.  Curetting,  therefore,  preceded  by  dilatation  and  followed 
by  gauze-packing,  is  by  far  the  safest  method  of  treating  these  cases ; 
and  when  repair  begins,  the  uterus  is  relieved  of  the  septic  process. 
As  Baldy  says,  "new  leucocytes  and  plasma  cells  are  not  forced  to  exercise 
their  phagocytic  properties  by  battling  Avith  pathogenic  germs,  but  the 
plasma  cells  have  a  healthy  pabulum,  and  devote  their  entire  energy  to 
the  work  of  regeneration,  which  is  not  merely  non-suppurative  repair, 
but  is  histological  growth." 

Reproduction  of  the  Endometrium.  —  After  a  thoroughly  antiseptic 
curetting  the  endometrium  is  reproduced  in  about  two  months,  that  is, 
between  the  second  and  third  catamenial  periods  following  the  operation. 
After  destruction  of   the  endometrium  by  acids  or  other  escharotics, 


V 


V 


V  1/      V  d 

Fio.  99.  —  Vertical  section  three  nidiulis  after  curetting,  a.  Epithelium;  h.  new-formed  plands ;  c, 
connective  tissue  ;  d,  muscular  tissue  of  the  uterine  walls  ;  v  r.  blood-vessels.  (From  Baldy's  Tes^t- 
Muflk  of  Gi/niecolo'j!/  hy  kind  permission  of  the  editor  of  the  Kouv.  Archir.  c/'oh.stei.  etde  gynicol.) 

suppuration  ensues,  with  the  formation  and  separation  of  a  slough ;  and 
the  endometrium  is  very  imperfectly  re-formed  after  the  lapse  of  three  or 
four  months.  In  both  cases  the  mucous  membrane  is  re-formed  mainly 
from  the  cells  of  the  connective  tissue  which  covers  the  muscle  layers  of 
the  uterus ;  but  there  is  an  essential  difference  in  the  new  membrane 
formed  under  these  circumstances.  After  chloride  of  zinc  paste  has  been 
iised  the  connective  tissue  layer  is  much  injured,  and  may  be  destroyed; 
for  the  action  of  this  caustic  is  very  uncertain,  and  may,  as  is  desired  by 
those  who  use  this  agent  for  cancer  of  the  uterine  body,  lead  to  destruc- 
tion of  the  muscle  also. 

After  curetting,  the  connective  tissue  is  rarely  injured ;  and  in  addition 
to  this,  it  is  more  than  probable  that  the  most  skilful  operator  would 
almost  invariably  leave  islets  of  mucosa  from  the  edges  of  which  new 
epithelium  would  spring.  The  bases  of  many  of  the  uterine  glands  also 
dip  down  so  far,  some  even  into  the  muscular  layer,  that  they  certainly 


298 


SYSTEM  OF  GYNECOLOGY 


would  not  be  readied  even  with  a  sharp  curette,  and  they  may  therefore 
be  additional  sources  of  epithelial  regeneration. 

Sections  of  a  uterus  taken  three  months  after  curetting  show 
(Eig.  99)  under  the  microscope  healthy  ciliated  epithelium,  with  newly 
formed  glands  dipping  down  into  the  connective  tissue,  which  is  richly 


icjL 


fmMmmSkimmJst; 


Fig.  100.  —  Vertical  section  of  the  uterine  mucous  membrane  fiftj'-five  days  after  the  application  of  a 
caustic,  a.  Epithelium;  h,  connective  tissue;  c  o,  section  of  the  glands  which  have  undergone 
cystic  dejfeiieration  ;  d,  tubular  (glands  enormously  dilated  ;  in.  muscular  tissue  of  the  uterine 
wall.  (P'rotri  l{aldy"s  Tewt- Hook  of  Gynmcology  by  kind  permission  of  the  editor  of  the  Noun. 
Architi.  d'olmUt.  et  de  ijynkcol.) 

supplied  with  blood-vessels.  In  other  words,  the  endometrium  is  ab- 
solutely normal.  This  happy  result  can  only  be  expected  when  no  fresh 
infection  of  the  Y)arts  has  meanwhile  occurred,  and  when  suppuration  has 
been  absent.  On  the  other  hand,  microscopical  sections  of  the  uterus 
following  the  use  of  chloride  of  zinc.  (Fig.  100)  show  an  imi)erfect  non- 
ciliated  fjiithelium,  greatly  exaggerated  connecitive  tissue,  and  a  few 
partially  formed  glands,  which  do  not  ojjen  on  to  the  surface  of  the 
endometrium,  but  are  mostly  distended  into  small  cysts  from  blocking 


GYNECOLOGICAL    TILERAPEUTICS  299 

of  their  surface  orifices.  The  condition  is,  in  fact,  one  of  chronic  inter- 
stitial endometritis,  with  its  accompanying  atrophy  of  the  epithelial 
elements. 

Pregnancy  after  the  use  of  an  escharotic,  used  as  assumed  above,  is 
very  rare.  After  curetting  it  is,  however,  very  common,  and  indeed,  in 
suitable  cases,  this  operation  has  cured  many  women  of  an  obstinate 
sterility.  Heinricius  collected  statistics  of  this,  and  showed  that  out 
of  o2  patients,  whose  history  after  curetting  he  was  able  to  learn,  16, 
or  oO  per  cent,  conceived ;  he  states  that  pregnancy  commenced  in  two 
cases  five  weeks,  and  in  one  case  eight  weeks  after  the  operation. 

Amand  Eouth. 

REFERENCES 

1.  Allbutt,  T.  Clifford.  Goulstonian  Lectures,  188'i.  —  2.  Auvard,  A.  Traits 
Pratiqxte  de  Gynsec.  1894.  —  3.  Ballaxce  and  Edmunds.  Treat,  on  the  Ligation  of 
Arteries,  1891,  pp.  259  and  271.— 4.   Baldy,  J.  M.     Text-Book  of  Gynsc.  1894,  p.  227. 

—  5.  Barnes,  Robert.  Diseases  of  Women,  etc.  —  6.  Braithwaite,  J.\mes.  Brit. 
Med.  Juur.  June  29,  1895,  p.  1438.  —  7.  Champneys,  F.  H.  Med.  Soc.  Tratis.  vol.  xv. 
1892,  p.  374.— 8.  Dickenson,  Dr.  R.  L.  Amer.  Jour,  of  Obstet.  Jan.  1895.— 9.  Doleris. 
Nouv.  Archiv.  d'obstel.  et  de  gyn.  vol.  vi.  p.  401.  — 10.  Ferria.  Gazetta  Medica  di 
Toriyio,  Dec.  13,  1894. —  11.  Goodell,  William.  Lessons  in  Gynsec.  p.  98;  Med. 
Gynsec.  1895.- 12.  Head,  Henry.  Brain,  vol.  xvi.  1893,  pp.  1  to  134.  — 13.  Hein- 
ricius. Gynxc.  og  Obstet.  Med.  vol.  vi.  No.  iii.  p.  134.  — 14.  Herman,  G.  E.  Obstet. 
Soc.  Trans,  vol.  xxxvi.  1894,  p.  250.-15.  Lewers,  A.  H.  N.  Lancet,  1891,  p.  1119.— 
16.  Malcolm,  J.  D.  Med.  Chir.  Trans,  vol.  Ixxi.  1888,  p.  43.  — 17.  Martin,  A. 
Path,  und  Tlier.  der  Frauenkr.  1887,  p.  26.  — 18.  More,  Madden.  Brit.  Med.  Jour. 
1884,  vt)l.  ii.  p.  1068.-19.  Olshausen.  Cent,  fiir  Gynsec.  July  1888.— 20.  Pesser, 
De.  Annal.de  Maladies  des  Org.  Gen.-win.  Jan.  18M. — 21.  Phillips,  John.  Lane. 
1887,  vol.  ii.  p.  507.  — 22.   Pozzi,  S.  (Syd.  Soc.)     Treat,  on  Gynsec.  1888,  pp.  31  and  141. 

—  23.  Rousing,  Theodore,  /fosp.  T'/d'»,ir/c,Feb.7, 1894.  — 24.  Routh,  Amand.  "Rapid 
Dilat.  of  Uterus,"  Med.  Soc.  Trans.  1892,  p.  347.-25.  Routh,  C.  H.  F.  "  Conserv.  Surg, 
in  Pelv.  Dis.,"  Mod.  Press  and  Circ.  May  1894.-26.  Ibid.  "Cases  of  Menorrhag. 
treated  by  the  Gouge,"  Obstet.  Soc.  Trans,  vol.  ii.  1860,  p.  117.-27.  Schroeder. 
Zeitsrh.  f.  Geb.  und  Gynak.  1881,  vol.  vi.  p.  29.-28.  Schultze,  B.  S.  Displace- 
metds  of  Uterus  (trans,  by  Dr.  Macan),  p.  222.-29.  Sloan,  C.  F.,  of  Ayr.  Ghisg.  Med. 
Jour.  vol.  X.  1862,  p.  281.- .30.  Tait,  Lawson.  Dis.  of  Ovaries,  4th  ed.  p.  .309; 
Brit.  Med.  Jour.  May  15,  1886,  p.  921.— 31.  Thomson,  H.  F.,  of  Dorpat.  Cent.  f. 
GvJh'cc.  vol.  xiii.  1889,"p.  409.  — 32.  Trelat.  Annal.  de  gyn.  et  d'ohstet.  Paris,  May 
1891.-33.  Treves,  F.  Lettsom:  Lect.  Med.  Soc.  Trans,  vol.  x\n.  1891.— M.  Vulliet. 
Nouv.  Archiv.  d'obstet.  et  de  gyn.  1886,  p.  693.-35.  Ibid.  Lerons  de  gyn.  nperatoire, 
1890,  p.  78.— .36.  Wright,  A.  E.  "Methods  of  Increasing  the  Coagulability  of  the 
Blood,"  Brit.  Med.  Jour.  July  14,  1894. 

A.  K 


SYSTEM  OF  GYNECOLOGY 


THE   ELECTRICAL   TREATMEIs^T   OF   DISEASES 
OF  WOMEN 

The  successful  employment  of  electricity  in  the  treatment  of  the  diseases 
of  women  is  of  very  recent  date.  General  attention  was  drawn  to  it  in 
1886,  when  Dr.  Georges  Apostoli  of  Paris  published  the  results  of  five 
years'  experience  of  its  use  in  this  class  of  cases,  and  at  the  same  time 
gave  a  full  account  of  the  method  by  which  he  carried  it  out.  That  the 
method  was  new  admits  of  no  discussion.  No  doubt  many  attempts  had 
been  made  in  previous  years  to  utilise  electric  energy  in  some  form  or 
other  for  this  purpose ;  but  the  knowledge  of  these  attempts  was  of  value 
to  Apostoli  only  in  so  far  as  it  showed  him  what  to  avoid. 

The  limits  of  this  article  do  not  permit  me  to  review  the  efforts  of 
earlier  workers  in  this  field ;  and,  indeed,  but  little  purpose  would  be 
served  by  such  a  review.  We  may  take  it  that  the  present  position  of 
electricity  in  gynaecology  is  simply  this,  that  it  consists  of  the  application 
of  Apostoli's  methods  with  such  slight  modification  of  details  as  has  been 
suggested  by  the  experience  of  workers  following  on  his  lines. 

I  purpose  in  the  following  pages  to  consider  this  subject  under  these 
heads :  —  1.  The  armamentarium,  or  instrumental  equipment,  required  in 
gynaecological  electro-therapeutics.  2.  The  modes  of  making  the  applica- 
tions. 3.  The  modes  of  action  of  the  current.  4.  The  diseased  con- 
ditions in  women  which  can  be  treated  by  electricity,  and  an  account  of 
the  modes  of  procedure  in  each. 

I.  The  Armamentarium.  — The  suitable  instrumental  equipment  of 
the  gy  neecologist  for  electrical  treatment  is  a  matter  of  the  first  importance, 
and  deserves  careful  consideration.  Much  of  the  disappointment  and 
failure  which  have  ensued  on  attempts  to  carry  out  electrical  treatment 
with  currents  of  relatively  considerable  strength  have  resulted  from  the 
unsuitable  nature  or  mismanagement  of  tlie  battery  and  other  instru- 
mental means  employed.  It  is  essential,  then,  that  the  apparatus  should 
be  suitable  and  well  cared  for,  otherwise  vexation  and  disappointment 
are  inevitable.  It  is  sometimes  forgotten  that  a  battery  is  capable  of 
giving  out  only  an  amount  of  energy  corresponding  to  its  size.  When 
an  ordinary  pm-table  "  constant  current "  battery  of  thirty  or  forty  small 
cells  is  found  exhausted  after  a  small  number  of  sittings  the  practitioner 
is  annoyed,  and  this  method  of  treatment  is  called  impracticable.  But 
the  faibire  is  due  to  the  employment  of  an  unsuita])le  and  inadequate 
source  of  energy. 

We  slia.ll  consider  first,  then,  the  most  convenient  and  suitable  form  of 
battery.  The  current  from  the  electric  lighting  mains  of  a  continuous 
low  pressure  supj>ly  is  the  most  convenient  source  of  energy  for  the 
purpose  in  view ;  but  this  source  is  not  as  yet  generally  available.    Con- 


THE   ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    301 


sequently  the  majority  of  practitioners  must  fall  back  upon  some  form  of 
primary  battery.  The  form  of  battery  Avill  depend  on  whether  the 
treatment  is  to  be  carried  out  in  the  physician's  rooms  or  at  the  patient's 
residence  ;  in  other  words,  whether  the  patient  is  to  come  to  the  batter3^, 
or  the  battery  is  to  go  to  the  patient.  There  can  be  no  doubt  that  the 
former  arrangement  is  much  the  more  satisfactory ;  it  permits  the  use 
of  a  large-celled  stationary  battery,  and  avoids  the  inevitable  incon-- 
venience  associated  with  the  carriage  of  a  portable  one.  I  shall  con- 
sider first  the  most  convenient  kind  of  stationary  battery. 

Experience  has  shown  that  some  form  of  Leclanche  cell  is  the  most 
suitable.  The  simplicity  of  its  construction  and  the  harmless  fluid  used 
are  matters  of  great  advantage.  Any  good  form  of  cell,  such  as  is 
used  for  electrical  bells  or  telegraph  work,  will  suffice.  An  excellent 
type  of  cell  is  sold  by  Mr.  K.  Schall  (Fig.  101).  The  carbon  element  is 
a  cylinder  about  2  inches  in  diameter,  pierced 
by  a  central  channel  1^-  inch  in  diameter. 
The  mouth  of  the  glass  jar  is  surrounded  by 
an  indiarrubber  collar,  which  supports  a  lead 
flange  attached  to  the  carbon  cylinder;  the 
carbon  thus  hangs  in  the  liquid,  being  half 
an  inch  clear  of  the  bottom  of  the  jar.  This 
space  prevents  the  formation  of  crystals  on 
the  lower  end  of  the  carbon.  In  the  central 
channel  hangs  the  zinc  rod ;  this  rod  is  attached 
to  a  china  disc  which  rests  on  the  top  of  the 
carbon  cylinder  in  such  a  way  as  to  prevent 
its  shifting  or  coming  in  contact  with  the 
carbon.  An  india-rubber  ring  is  slipped  over 
the  lower  end  of  the  zinc  rod,  which  effectually 
prevents  its  touching  the  carbon  cylinder  at 
that  point.  The  cell  is  thus  of  a  simple  and  workmanlike  construction, 
and  has  a  very  low  internal  resistance  —  a  matter  of  some  consequence. 
"Whatever  kind  of  cell  is  used  it  should  be  of  at  least  a  quart  capacity. 
Erom  thirty  to  forty  of  such  cells  will  be  required. 

The  efficiency  and  length  of  life  of  such  a  battery  will  depend  largely 
on  the  manner  in  which  it  is  charged  and  set  up;  and  the  following 
instructions  may  be  found  of  use :  —  The  glass  jars  after  being  iinpacked 
should  be  wiped  inside  and  out  with  a  dry  cloth  so  as  carefully  to  free 
them  from  straw  and  dust.  Care  should  be  taken  not  to  damage  in  any 
way  the  coating  of  paraffin  round  the  outer  edge ;  the  object  of  the 
paraffin  is  to  prevent  "  creeping,"  and  if  it  should  be  deficient  or  cracked 
it  should  be  repaired  by  brushing  a  little  melted  paraffin  over  it^ 
The  jar  should  then  be  rather  more  than  half  filled  with  a  saturated 
solution  of  sal  ammoniac.  The  salt  used  should  be  nearly  pure ;  the 
common  or  commercial  form  gives  very  unsatisfactory  results.  The 
rubber  collars  are  then  to  bo  fitted,  and  the  carbon  cylinders  put  in. 
Great  care  should  be  taken  that  the  outside  of  the  jars  be  not  wetted  by 


Fig.  litl.  —  Leclanche  cell. 


302  SYSTEM  OF  GWWECOLOGY 

sparking  of  the  fluid.  Tlie  introduction  of  the  carbon  will  raise  the  fluid 
within  '1  inches  of  the  shoulder  of  the  cell.  The  cell  should  be  allowed 
to  stand  for  twenty -four  hours,  at  the  end  of  which  time  the  fluid  will 
have  sunk  a  little  owing  to  the  absorption  of  some  of  it  by  the  porous 
carbon.  The  cells  are  now  to  be  filled  with  plain  water  to  a  level  of  o]ie 
inch  below  the  shoulder ;  this  will  reduce  the  saturation  somewhat,  and 
avoid  the  risk  of  any  part  of  the  salt  crystallising  out.  If  the  fluid  used 
be  fully  saturated  this  change  is  apt  to  occur  in  cold  weather,  and  crystals, 
forming  in  the  space  roiuid  the  zinc  rod,  may  ultimately  make  a  bridge 
between  the  elements,  an  accident  which  will  rapidly  destroy  the  cell. 
The  zinc  rods  may  then  be  placed  in  position,  and  the  cells  arranged  in 
their  permanent  places.  The  most  convenient  place  is  a  dry  roomy  cup- 
l^oard,  the  shelves  of  which  should  be  varnished  or  covered  with  thick 
brown  glazed  paper.  If  a  cupboard  be  not  available,  stout  shelves  must 
be  provided.  If  forty  cells  are  employed  they  should  be  arranged  in  two 
sets  of  twenty  cells  each  on  two  shelves,  each  set  consisting  of  two  rows 
of  ten  cells.  A  clear  inch  should  be  allowed  between  each  cell,  and  two 
or  three  between  each  row.  In  this  way  any  cell  can  readily  be  removed 
for  any  purpose,  and  the  cells  periodically  tested  as  to  efl&ciency.  Before 
being  placed  on  the  shelf  each  cell  must  be  carefully  dried  from  any  stray 
drops  of  solution  or  moisture  which  may  have  been  deposited  on  it.  This 
precaution  should  not  be  omitted,  as  the  efficiency  and  durability  of  the 
battery  greatly  depend  on  keeping  the  cells  thoroughly  dry  on  their 
external  surface.  The  cells  may  now  be  connected  up ;  the  carbon  of 
each  should  be  joined  to  the  zinc  of  the  next  by  a  piece  of  clean  No.  18 
copper  wire,  care  being  taken  that  the  binding  screws  are  well  screwed 
up  and  the  wires  firmly  held  by  them.  This  will  leave  a  free  carbon  and 
a  free  zinc  at  the  end  of  the  battery ;  from  these,  pieces  of  insulated  wire 
should  run  to  a  couple  of  stout  binding  screws  fixed  to  one  of  the  shelves. 
The  binding  screw  connected  with  the  last  carbon  will  be  the  positive,  and 
that  connected  with  the  last  zinc  will  be  the  negative  pole  of  the  battery. 
A  battery  consisting,  say,  of  forty  cells,  if  tested  by  a  volt  meter,  should 
give  an  electro-motive  force  of  about  58  volts ;  and  as  the  resistance  of 
each  cell,  when  in  good  condition,  is  about  0-5  ohm,  the  total  resistance 
of  the  battery  will  be  about  20  ohius.  On  short  circuit,  then,  the  battery 
will  give,  for  a  short  time,  nearly  2-5  amperes.  With  a  good  abdominal 
electrode  yjroperly  applied,  and  a  sound  in  the  uterus,  the  resistance  of 
the  human  body  averages  about  150  ohms ;  thus  the  battery  will  be 
capable  of  transmitting  a  current  of  about  one-third  of  an  ampere  through 
the  tissues  of  the  patient.  This  is  more  than  suflicient  for  all  ordinary 
purposes ;  but  as  the  electro-motive  force  tends  to  fall  and  the  internal 
resistance  to  rise,  it  is  well  to  be  provided  at  the  outset  with  a  certain 
amount  of  surplus  energy.  If  properly  used  and  cared  for,  siuih  a  battery 
will  prove  eific.ieiit  for  a  very  long  time.  The  following  matters  must 
be  attended  to  it  disappointment  is  to  bo  avoided:  —  1st,  The  l)attery 
should  not  be  allowed  to  remain  idle  for  long  intervals:  if  it  happen 
not  to  be  used  foi'  a  few  weeks  at  a  time,  crystals  tend  to  form  on 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    303 

the  zincs,  and  when  next  examined  the  internal  resistance  will  be  found 
greatly  increased.  If  the  battery  is  not  to  be  used  for  a  week  or  two,  the 
terminlas  ought  to  be  connected  to  a  resistance,  and  a  current  of  50  or  60 
inilliamperes  allowed  to  flow  for  five  or  six  minutes  at  least  once  a  fort- 
night. Attention  to  this  will  do  much  to  prolong  the  life  of  a  battery ; 
nothing  is  worse  for  it  than  long  periods  of  idleness.  2nd,  From  time  to 
time  the  evaporation  from  the  vessels  should  be  made  good  by  the  addition 
of  a  little  water.  3rd,  Once  a  month  each  cell  should  be  tested  with  a 
galvanometer  to  see  that  it  is  giving  its  proper  quota  of  energy.  This 
can  be  done  without  disconnecting  the  cells,  by  having  two  stiff  copper 
wires  attached  to  flexible  leads  connected  with  the  galvanometer,  with 
which  the  terminals  of  each  cell  may  be  touched.  If  any  cell  gives  a 
smaller  deflection  than  it  should  do,  it  should  be  removed  and  examined 
for  the  cause  of  the  defect.  This  may  be  creeping  of  the  fluid  over  the 
edge  of  the  cell,  or  accidental  contact  of  the  plates  in  the  fluid.  The 
defect  should  be  rectified,  and  the  cell  tested  and  returned  to  its  place ; 
but  the  battery  may,  of  course,  be  used  without  the  defective  cell  if  those 


Fif:.  102.  —Carbon  rheo&taL 

on  each  side  of  it  be  connected  by  a  piece  of  stout  copper  wire.  4th, 
Any  fluid  accidentally  spilt  on  or  about  the  cells  should  be  carefully 
dried  up  at  once. 

AVhen  such  a  battery  has  been  in  use  for  two  or  three  years  it  will 
show  signs  of  exhaustion  5  it  should  then  be  taken  apart,  the  solution 
replaced  by  a  fresh  quantity,  and  the  zincs  reamalgamated.  Any  of  the 
latter  which  are  much  worn  should  be  replaced  by  neAv  ones:  this 
may  be  done  at  the  cost  of  a  few  pence  for  each  rod.  With  careful  and 
regular  use,  and  an  overhaul  now  and  then,  a  battery  of  this  sort  may 
remain  in  good  working  order  for  an  indefinite  time. 

Tlie  Current  Regulator.  —  For  the  control  of  this  or  any  other  battery 
some  form  of  current  regulator  is  necessary.  For  portable  batteries  the 
cell  collector  is  probably  the  most  convenient  means ;  but  for  a  fixed 
installation  such  an  arrangement  is  impracticable.  The  regulation  in  this 
case  is  best  effected  by  some  form  of  rheostat  or  adjustable  resistance. 
The  most  convenient  form  of  rheostat  at  present  available  is  one  made 
of  filaments  or  thin  rods  of  carbon,  which  can  be  cut  out  or  introduced 
into  the  circuit  gradually  by  means  of  sliding  metal  pieces  (Fig.  102). 
This  arrangement  permits  of  increase  or  diminution  of  the  current  to  any 
extent  without  the  least  interruption  or  shock  —  a  matter  of  essential 
consequence  in  the  use  of  strong  currents.     Four  of  these  rheostats, 


304 


SYSTEM  OF  GYNECOLOGY 


mounted  in  series,  will  be  found  a  convenient  combination ;  and  the 
following  approximate  values  will  be  suitable :  Ko.  1  of  200  ohms ; 
No.  2  of  100()  ohms ;  No.  3  of  10,000  ohms ;  No.  4  of  100,000  ohms. 
With  such  a  combination  inserted  into  the  circuit  between  the  battery 
and  the  patient  about  2  milliamperes  of  current  will  pass,  so  that  the 
patient  may  be  connected  to  the  terminals  without  any  appreciable 
shock. 

Liquid  rheostats  have  been  devised  for  this  purpose ;  but,  although 
they  are  cheaper  than  those  just  described,  they  are  very  apt  to  get  out 
of  order,  and  seldom  can  be  regulated  through  the  necessary  range. 
They  are  thus  very  unsatisfactory.  Rheostats  consisting  of  graduated 
coils  of  wire,  which  can  be  switched  in  or  out  of  the  circuit,  have  been 
employed;  they  are  costly,  and  they  are  also  unsatisfactory,  because  the 
passage  from  one  coil  to  another  means  a  more  or  less  abrupt  drop  in  the 
resistance  with  a  corresponding  abrupt  rise  in  the  current.  The  patient 
is  thus  subjected  to  a  series  of  unpleasant  shocks,  and  this  defect  alone 
is  enough  to  condemn  them. 

Tlie  Galvanometer.  —  A  galvanometer  calibrated  to  read  directly  in 
milliamperes  (hence  termed  a  milliampere  meter)  is  an  essential  part 
of  the  apparatus.  These  are  now  comparatively  cheap,  and  are  so 
coustructed  as  to  be  readily  portable.  Probably  the  most  con- 
venient form  is  that  made  by  Dr.  Edelmann  of  Munich.  These 
instruments  are  fairly  accurate,  wear  well,  and  can  be  readily  transported 
if  need  be.  The  best  form  is  that  in  which  the  needle  is  suspended  by  a 
silk  fibre ;  for,  however  satisfactory  the  pivoted  form  of  magnet  may  be 
at  first,  it  becomes  less  so  by  use  on  account  of  the  blunting  of  the  pivot 
by  continued  swinging.  Edelmann's  instruments  are  nearly  dead  beat, 
that  is,  after  the  passage  of  a  current  the  needle  assumes  its  proper 

position,  with  one  or  two  small  oscilla- 
tions only.  This  is  an  undoubted 
advantage,  as  the  current  can  be 
quickly  adjusted  and  read  off. 

A  convenient  instrument  sold 
by  Mr.  Schall  is  shown  in  Fig.  103. 
The  dial  of  this  instrument  is  divided 
into  fifty  divisions :  with  both  shunts 
withdrawn,  each  division  represents 
0-1  ni.a. ;  with  the  10  shunt  screwed 
in,  each  division  rci:)resents  1  m.a. ; 
with  the  100  shunt  screwed  in,  each 
division  indicates  10  m.a. :  thus  the 
total  range  is  from  0-1  m.a.  to  500 
m.a.  For  those  who  desire  an  in- 
instrument  of  the  highest  class,  the  milliampere  meter,  made  specially  for 
physicians'  use  by  the  Weston  Electrical  Company  of  America,  may  be 
strongly  recommended  (Fig.  104).  These  instruments  are  beautifully 
(;<mstructed,  accurately  adjusted,  and  absolutely  dead  beat.     Moreover 


Fk;.  10.';.  —  lOilriiiKiiiii  ^'al variometer. 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    305 


they  are  quite  portable,  require  no  levelling,  and  seem  to  undergo  no 
change  by  continued  use ;  they  are,  however,  somewhat  costly.  They 
may  be  obtained  from  Elliott  Brothers,  of 
101  St.  Martin's  Lane. 

When  any  of  the  swinging  magnet 
galvanometers  are  used  they  must  be  set  up 
on  a  level  surface  or  adjusted  by  levelling 
screws ;  the  instrument  must  then  be  so 
turned  that  the  needle  points  to  zero  on  the 
scale.  These  galvanometers  should  be  kept 
as  far  away  as  possible  from  anything  made 
of  iron,  such  as  a  grate,  stove,  or  iron 
bracket.  With  the  Weston  instrument 
such   a   precaution  is  unnecessary ;    they 


Fig.  104. 


-Weston  inilliauipfere  meter. 

may  be  set  down  on  any 
surface,  and  the  vicinity  of  iron  does  not  influence  them. 

Connecting  tdres  must  be  provided  to  convey  the  current  from  the 
battery  to  the  patient.  These  may  conveniently  be  made  of  copper  wire 
(No.  18)  insulated  with  india-rubber  covered  with  cotton  or  silk  ;  or  they 
may  be  made  of  the  stranded  flexible  cord  used  for  pendant  electric  lights. 
They  should  be  at  least  4  feet  in  length,  and  of  different  colours,  so  that 
they  can  be  readily  distinguished. 

Electrodes.  —  By  electrodes  we  mean  the  special  appliances  by  which 
we  bring  the  current  into  contact  with  the  patient.  In  gynaecological 
therapeutics  Ave  distinguish  them  by  the  terms  internal  and  external, 
according  as  they  are  to  be  introduced  into  the  interior  of  the  body  or 
applied  to  the  skin.  They  are  of  course  electrically  distinguished  by  the 
pole  with  which  they  are  connected. 

Internal  electrodes  may  be  introduced  into  the  uterus  or  simply  into 
the  vagina.  The  intra-uterine  electrode  usually  takes  the  form  of  a  sound. 
The  most  generally  convenient  form  is  one  made  like  an  ordinary  uterine 
sound,  the  three  or  four  inches  at  the  point  being  made  of  platinum  (Fig. 
105).    To  the  handle  is  fixed  a  binding  screw  for  attachment  of  the  flexible 


Fig.  105.  —  Intr.i-utcrine  electrode. 


conductor.  A  gum  elastic  or  celluloid  sheath  slides  on  the  sound  and 
can  be  clamped  at  any  point,  so  as  to  expose  more  or  less  of  the  platinum 
end.  In  this  way  a  greater  or  a  smaller  part  of  the  uterine  surface  is 
brought  directly  in  contact  with  the  metallic  surface  of  the  electrode, 
and  so  with  the  current.  In  certain  cases,  as  we  shall  see  later,  the  best 
results  are  obtained  by  limiting  the  area  of  contact  to  a  considerable 
extent.  For  this  purpose  Apostoli  uses  electrodes  having  carbon  ends 
about  0-75  inch  in  length  (Fig.  106).     By  moving  this  along  the  uterine 


3o6  SYSTEM   OF  GYNECOLOGY 

canal  successive  portions  may  be  treated  at  will.     These  electrodes  are, 
however,  straight  and  often  difficult  if  not  impossible  to  introduce.     I 


Fig.  100.  —  Apostoli's  carbon  electrode. 

have  used  a  sound  which  is  about  the  diameter  of  a  No.  10  bougie  (Fig. 
107).  This  is  insulated  up  to  half  an  inch  from  the  point.  This  half  inch 
consists  of  platinum  of  the  same  diameter  as  the  rest  of  the  sound,  and 
is  screwed  to  a  copper  rod  passing  down  to  the  handle  and  ending  in  a 
binding  screw.  The  position  of  the  platinum  tip  can  be  regulated  and 
adjusted  in  the  uterus  by  means  of  the  sliding  collar  which  is  connected 
to  a  gauge  on  the  handle.  This  electrode  can  be  readily  passed  into  any 
uterus  the  cervical  canal  of  which  is  sufficiently  wide  to  admit  it ;  and  in 
the  cases  where  the  treatment  is  specially  useful  this  condition  is  generally 


Fig.  107.  —  Adjustable  platinum  electrode. 

present.  In  cases  where  the  cervix  is  so  displaced  by  a  fibroid  that  it  can- 
not be  reached,  or  in  case  it  be  impossible  to  introduce  the  sounds  described, 
it  will  be  necessary  to  puncture  the  tumour  at  its  most  prominent  point,  so 
as  to  carry  the  current  directly  into  its  substance  ;  for  this  purpose  some 
form  of  pointed  electrode  must  be  used.  Apostoli  recommends  the  use 
of  an  instrument  constructed  like  the  ordinary  sound  electrode,  but  ending 
in  a  sharp  point ;  this  is  inserted  into  the  mass  for  about  1  cm.,  and  the 
sheath  is  then  pushed  up  to  the  vaginal  roof.  The  objection  to  this 
method  is  that  the  tissue  of  the  roof  is  electrolysed,  and  an  open  sinus 
is  formed  leading  from  the  vagina  to  the  deepest  part  of  the  puncture. 
This  lesion  is  obviously  not  free  from  risk  of  septic  infection  passing  from 
the  vagina  into  the  tissue  of  the  tumour.  A  better  plan  is  to  use  a  needle 
similar  to  that  employed  for  the  electrolysis  of  aneurysms  or  nsevi,  but 
of  course  much  larger  (Fig.  108).     The  rubber  insulation  of  this  stops 


Fig.  108.  —  Electrode  for  iiuncture. 


about  \  inch  from  the  point,  which  is  of  course  sharp ;  thus  the  needle 
can  be  j^lunged  well  into  the  tumour,  the  rubber  sheath  i)assing  through 
the  vaginal  roof,  which  is  thus  merely  punctured,  not  electrolysed;  and 
on  the  withdrawal  of  the  needle  tlie  ymncture  closes  up  again.  The 
electrolysis  is  thus  confined  to  the  tissue  of  the  tumour. 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    307 


Vaginal  electrodes  may  be  made  of  plain  metal  bulbs  carried  on  an 
insulated  stem,  or  the  bulb  may  be  covered  by  a  piece  of  cotton  soaked 
in  salt  solution  (Fig.  109). 

The  External  Electrode.  —  The  purpose  of  the  external  electrode  is  to 
distribute  the  current,  as  it  enters  or  leaves  the  body,  over  as  large  an 
area  of  skin  surface  as  practicable.  The  result  is  so  to  diminish  the 
cutaneous  resistance  as  to  permit  the  passage  of  a  current  of  (-onsiderable 
strength  by  means  of  a  moderate  electro-motive  force ;  and  this  without 
the  production  of  much  pain.  The  main  points  in  the  selection  of  the 
electrode  then  are  tliese :  1st,  it  must  be  a  good  conductor ;  2nd,  it  must 
cover  as  much  of  the  abdomen  as  practicable  ;  and,  3rd,  it  must  make  good 
contact  with  the  moistened  skin. 


Fic.  109.  — Vagina!  electrodes. 


The  external  electrode  first  recommended  by  Apostoli,  and  still 
used  by  him  and  others,  is  made  of  moistened  sculptor's  clay  rolled 
into  a  suita1)]e  thickness,  and  sufficiently  large  to  cover  the  greater  part 
of  the  anterior  abdominal  wall.  The  clay  is  moistened  with  water  and 
a  little  glycerine,  and  rolled  to  a  stiff  consistence  with  a  rolling  pin.  It 
should  be  about  half  an  inch  in  thickness,  and  about  10  by  8  inches  in 
area.  The  clay  should  then  be  placed  on  a  piece  of  muslin  large  enough 
to  extend  about  3  inches  beyond  the  electrode  all  round ;  by  this  edge 
the  electrode  can  be  readily  lifted  and  placed  on  the  abdomen,  the 
muslin  being  next  the  skin.  A  thin  sheet  of  lead,  about  (5  inches 
s(iuare,  is  then  placed  on  the  clay  and  pressed  into  it,  and  to  this  one 
of  the  connecting  cords  is  attached.  The  undoubted  advantage  of  this 
<'lectrode  is  that  it  forms  an  excellent  contact  with  the  skin,  moulding 
itself  to  all  the  elevations  and  hollows,  and  so  reducing  the  resistance 
to  a  minimum.  It  is  certainly  easier  to  transmit  heavy  currents  by  this- 
electrode  than  by  any  other.  Its  disadvantages  are,  that  in  spite  of  every 
care  it  is  troublesome  to  make  ready,  and  apt  to  be  very  dirty ;  and 
as  it  is  most  effective  when  applied  cold,  it  is  unpleasant  to  the  pa- 
tient. If  warmed  it  is  apt  to  become  dry  on  the  surface,  and  thus  to 
lose  its  efficiency.  There  are,  however,  a  number  of  external  electrodes 
which  make  good  substitutes  for  the  clay;  and  experience  has  shown 
that  in  most  cases  it  is  not  necessary  to  employ  the  very  high  currents 
first  recommended  which  can  certainly  be  best  transmitted  by  means  of 
the  clay.     For  most  cases  a  simpler  and  pleasanter  form  of  electrode 


3oS  SYSTEM  OF  GYNECOLOGY 

may  be  employed:  thus  a  double  fold  of  thick  flanuel,  about  10  inches 
square,  soaked  in  a  warm  solution  of  salt  in  water,  and  laid  carefully  on 
the  abdomen,  makes  a  good  contact ;  upon  this  a  plate  of  lead  or  zinc, 
about  4  inches  square,  should  be  laid,  and  connected  by  a  binding  screw 
with  one  of  the  connecting  cords.  A  piece  of  mackintosh  laid  on  the 
whole  will  prevent  the  moisture  from  escaping  or  wetting  the  dress. 
Again,  a  piece  of  sheet  lead  of  sufficient  size  may  be  thickly  padded 
with  cotton  wool  on  one  side  ;  when  this  is  soaked  in  salt  water  it 
makes  a  good  conductor,  and  will  make  close  contact  with  the  skin. 

One  of  the  best  of  these  electrodes,  according  to  my  oAvn  experi- 
ence, is  supplied  b}^  Mr.  Coxeter.  It  is  made  of  a  sheet  of  brass  wire 
cloth  on  which  a  composition,  consisting  mainly  of  gelatine,  has  been 
poured.  The  surface  of  the  gelatine  is  made  very  smooth.  This  is 
sponged  over  with  plain  warm  water  until  it  is  slightly  softened,  and  it 
is  then  carefully  laid  on  the  abdomen:  if  pressed  down  all  round  it 
will  adhere  slightlj^to  the  skin,  making  very  intimate  contact,  and  offering 
slight  resistance.  Currents  of  considerable  intensity  — 150  to  200  m.a. 
—  may  be  transmitted  by  means  of  this  electrode ;  and  if  carefully 
juade  so  as  to  be  free  from  air  spaces,  it  will  last  for  a  long  time.  When 
it  has  become  rough  on  the  surface  it  may  be  smoothed  by  means  of  a 
liot  knife  passed  carefully  over  it.  Several  other  materials  have  been 
recommended,  but  one  or  other  of  these  described  will  be  found  sufficient 
for  all  purposes. 

With  such  an  equipment  the  gynaecologist  is  in  a  position  to  make 
all  the  applications  of  the  continuous  current  which  experience  has  shown 
to  be  of  practical  use.  It  is,  of  course,  presumed  that  the  i:)atients  are 
to  attend  for  treatment;  and  there  can  \>e  no  doubt  that  the  best  results 
are  obtained  when  this  can  be  arranged.  The  stationary  battery  can 
with  reasonable  care  be  relied  on  to  do  its  work  in  a  way  which  never 
can  be  expected  from  any  form  of  portable  battery,  all  of  Avhich  are 
liable  to  disorganisation  from  a  variety  of  conditions  which  cannot  al- 
ways be  foreseen  or  provided  against. 

Nevertheless  it  may  be  convenient  or  necessary  on  occasion  to  con- 
duct the  treatment  by  electricity  at  the  residence  of  a  patient ;  in  this 
case,  of  course,  a  portable  battery  must  be  employed.  Hence  it  will  be 
advisable  to  say  a  word  or  two  al)out  the  most  suitable  instrument  for 
this  purjiose.  A  battery  of  thirty  or  forty  cells  will  be  required.  The 
Leclanche  element  is  again  the  most  suitable.  A  very  convenient 
battery  is  made  by  Schall  (Fig.  110).  This  contains  the  requisite  num- 
ber of  elements,  and  is  fitted  with  a  double  collector,  by  which  not  only 
can  the  cells  be  introduced  into  the  circuit  one  by  one,  but  any  set  or 
group  of  cells  can  be  selected,  so  that  the  battery  can  be  evenly  and  thus 
economically  used.  In  place  of  the  "collector"  a  rheostat  may  be  used 
similar  to  tlie  one  already  described.  This  will  be  found  convenient,  but 
it  is  more  costly.  A  galvanometer  is  fitted  to  this  instrument  so  that 
nothing  in  addition  but  the  electrodes  is  required.  Such  a  battery  is  not 
unduly  heavy  —  about  ."xS  lbs.  —  and  is  thus  fairly  portable.     It  is,  how- 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    309 

ever,  liable  to  accident  by  careless  use.  and  if  \dolently  jolted  may  be 
damaged  by  the  cracking  of  a  cell.  If  kept  in  good  order  it  may  give 
from  sixty  to  seventy  applications  of  average  strength  and  duration, 
after  which  its  electro-motive  force  -will  begin  to  fall  and  its  internal 
resistance  to  rise,  so  that  the  available  current  will  be  greatly  reduced. 
In  these  batteries  the  cells  should  be  tested  from  time  to  time,  and  any 
defective  one  at  once  removed  and  replaced  by  another  until  it  can  be 
repaired.    Tor  this  reason  it  is  advisable  to  have  a  few  spare  cells  at  hand. 


Fig.  110.  —  Portable  battery  witb  collector  and  galvanometer. 

Induced,  altematinrj,  or  "faradic '"  ao'renfs  are  frequently  employed  in 
gynaecology,  and  for  the  production  of  these  many  convenient  appliances 
are  available.  The  most  convenient  portable  faradic  apparatus  is  that 
known  as  Spamer's  ;  the  whole  apparatus  is  contained  in  a  box  5  inches 
s(|uare,  and  includes  a  bichromate  cell  and  coil  with  the  necessary  con- 
nections. For  use  in  the  consulting  room  ^Iv.  Coxeter  and  Mr.  Schall 
both  sup])ly  very  excellent  coils  of  the  Pubois  Eeymoiul  jiattcrn,  Avhich 
can  be  excited  by  two  large  Leclanche  cells,  or  by  a  bichromate  cell. 
In  these  the  rate  of  interruption  can  be  widely  varied,  and  the  strength 
adjusted  by  the  sliding  of  the  secondary  on  or  away  from  the  ]irimary. 
It  is  advisable  in  these  last  patterns  to  have  two  secondary  coils,  one  of 
many  turns  of  thin  wire,  say  5000,  and  the  other  of  a  smaller  number 


SYSTEM  OF  GYNECOLOGY 


Fig.  111.  ■ 


ijiiuA.iUiiiiiuffS'ullniiiniiililllliB 
-Spamer's  Induction  coil. 


Fio.  112. — Sledfjc  induction  cuil. 

of  turns  of  thick  wire,  say  200.  The  electro-motive  force  of  the  two 
differs  in  proportion  to  the  turns  on  the  coil.  Convenient  forms  of  such 
instruments  are  shown  in  Tiers.  Ill  and  112. 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    311 

It  is  now  necessary  to  consider  tlie  way  in  which  the  j^ieces  of  apparatus 
described  above  are  to  be  coimected  up  for  use.  AVe  shall  presume  that  a 
stationary  battery  of  the  kind  described  is  to  be  employed.  A  level 
table  or  shelf  must  be  provided  close  to  the  couch  on  which  the  patient 
is  to  lie.  The  rheostat  and  galvanometer  are  arranged  on  this  shelf  or 
table,  and  an  insulated  flexible  wire  is  to  be  brought  from,  say,  the 
positive  terminal,  and  firmly  connected  to  one  of  the  binding  screws  of 
the  rheostat.     A  similar  wire  is  brought  from  the  negative  terminal  of 


Ucg:ulator  switch  board  for  oontimious  and  induced  currents. 


the  battery  and  connected  to  one  of  the  binding  screws  of  the  galva- 
nometer. The  slides  of  the  rheostat  must  be  so  arranged  that  the  full 
resistance  is  in  circuit,  while  the  galvanometer  must  be  so  adjusted  that 
the  needle  points  to  zero.  If  it  is  proposed  to  use  a  current  of  more 
than  50  m.a.  the  100  shunt  must  be  screwed  in;  if  less  than  50  m.;i. 
the  100  shunt  must  be  withdrawn  and  the  10  shunt  screwed  in.  Tlic 
flexible  connecting  cords  must  then  be  attached  to  the  rheostat  and  the 
galvanometer,  the  one  attached  to  the  former  being  now  the  positive 
pole,  and  that  to  the  latter  being  the  negative.  These  are  now  ready  to 
be  attached  to  the  respective  electrodes,  after  the  latter  have  been 
adapted  to  the  patient. 


SYSTEM  OF  GYNMCOLOGY 


When  a  nimiber  of  patients  are  under  regular  treatment  it  is  advis- 
able and  most  convenient  to  have  the  various  instruments  permanently 
connected  up  on  a  kind  of  switch  board ;  so  that,  after  applying  the  elec- 
trodes to  the  patient,  it  is  only  necessary  to  connect  the  electrodes  to  the 
conducting  cords  and  turn  on  the  current.  Such  an  arrangement  is 
shown  in  the  accompanying  figure,  which  illustrates  the  switch  board 
(Fig.  113)  employed  by  myself  for  a  number  of  years,  and  which  I  have 
found  exceedingly  convenient. 

As  already  mentioned,  there  is  no  doubt  that  the  most  convenient 
soiu'ce  of  energy  for  electrical  treatment  is  the  lighting  mains  of  a  con- 
tinuous low  pressure  supply.  There  are  two  ways  in  which  the  current 
strength  may  be  regulated :  1st,  the  patient  may  be  put  in  the  main 
circuit  with  a  resistanc^e  interpolated,  sufficient  to  reduce  the  current,  so 
that  not  more  than  one  or  two  m.a.  will  pass.  One  hundred  thousand 
ohms  will  be  required  to  do  this.  The  switch  board  shown  in  the  pre- 
ceding figure  will  serve  the  purpose  very  well,  and  another  made  by 

Schall  is  shown  in  Fig.  114.     The 

objection  to  this  method  is  that 

9tL  ,fr K^T'Ti'/MI^  ^^  ^^  '^^   moment  of   making   and 

/^      ^HP^P^    ^V  ^-^^^    ^^    breaking     contact    the 

_•        e     !|-^~T^^^^!^         1  patient  experiences  a  som.ewhat 

jpJ  'Tffiia  ^MsM"  Tl  sharp    and    disagreeable    shock, 

owing  to  the  high  voltage ;  2nd, 
the  patient  may  be  in  a  shunt 
circuit.  This  arrangement  is 
shown  diagrammatically  in  Fig. 
115.  The  current  from  the  main 
passes  to  the  resistance  R.  The 
patient  is  in  a  shunt  circuit  con- 
nected with  one  end  of  the  resist- 
ance and  the  slider  M.  By  shift- 
ing the  position  of  the  latter  the 
voltage  of  this  shunt  circuit  can 
be  raised  from  0-1  volt  to  50  or 
GO  volts ;  and  in  this  way,  with- 
out shock  or  interruption  of 
any  kind,  the  current  can  be 
varied  from  a  fraction  of  a 
milliampere  to  the  required 
strength.  A  convenient  switch 
l)()ard  fitted  on  this  principle 
by  Schall  is  shown  in  Fig.  IIG. 
In  all  cases  where  current  is 
taken  from  the  mains  an  eight 
or  sixteen  candle  power  lamp  should  be  interpolated.  Tliis  acts  as  a 
safety  resistance,  and  prievents  the  passage  of  more  than  250  m.a.  in 
the  former  case,  or  500  m.a.  in  the  latter. 


114.  —  Switch  board  for  rcfjulatlng  lightin;,' 
rifiits  by  mean!*  of  rcHlstances. 


THE   ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    313 


II.    Mode  of  Making  the  Applications. — We  may  now  consider  the 
details  of  the  procedure  for  administration  of  the  current.    Careful  atten- 


FiG.  115. —Diagram  of  switch  board  for  regulating  lighting  currents  by  means  of  shunt. 

tion  to  these  details  is  essential  to  success  and  to  the  avoidance  of  serious 

accidents.     It  must  be  carefully  kept  in  mind  that  the  use  of  currents  of 

100  m.a.  and  upwards  is  not  free  from 

danger,  and  that  serious  mischief  may 

result  from  carelessness  in  their  use. 

The  patient  should  be  directed  before 

attending  to  take  a  vaginal  douche  of 

warm  (105°  F.)  water  made  antiseptic 

l)y  carbolic  acid  1—40.     This  should  be 

copious,  two  quarts  at  least.    On  arrival 

she  should  remove  her  ordinary  clothes, 

and  put  on  a  night  and   a  dressing 

gown,  the  latter  made  so  as  to  open 

completely  down  the  front.     She  wears 

her  stockings   of   course,   and   should 

also  put  on  warm  slippers.    She  should 

now   lie    down    on   the   couch,   Avhich 

should  be  moderately  high  and  firm, 

and  should  be  covered  with  a  rug  or 

blanket.      In   cold   weather   her    feet 

should  rest  on  a  hot  water  bottle. 

Let  us  suppose  that  a  continuous 
current  is  to  be  applied  to  the  interior 
of  the  uterus  for  the  treatment  of 
hamiorrhage.endometritis,  and  so  forth.  '^^--^  -   ~^ 

A  suitable  sound-electrode  having  been  i'"'-  hg-  -&-"'■'>  »''^="'i  '""'•  ^^i"'"'  ■•'■f-'"i»<'"n- 
chosen,  it  must  now  be  passed  into  the  uterus.  This  may  be  done  with  the 
patient  on  her  back :  if,  however,  as  is  usual  in  this  country,  the  gynaecologist 


314  SYSTEM  OF  GYNECOLOGY 

is  in  the  habit  of  passing  the  sound  with  the  patient  on  her  left  side,  there 
is  no  reason  why  this  position  should  not  be  retained.  When  the  sound  is 
passed  the  finger  is  still  kept  against  the  cervix  in  order  to  keep  the  sound 
in  position,  and  the  patient  is  asked  to  roll  slowly  round  onto  her  back,  and 
while  she  is  doing  this  care  must  be  taken  that  the  sound  does  not  slip. 
AMien  the  patient  is  comfortably  settled  on  her  back  the  connecting  cord 
from  the  proper  pole  must  be  attached,  and  the  handle  of  the  sound  given 
to  the  nurse  or  attendant  whose  duty  it  is  to  be  by  the  side  of  the  couch, 
and  to  hold  the  sound  steadily  all  through  the  sitting.  The  dressing- 
gown  is  now  to  be  opened,  and  the  night-gown  drawn  up  so  as  to  expose 
the  abdomen  up  to  the  pit  of  the  stomach.  The  abdomen  should  be 
sponged  with  warm  salt  solution,  and  any  abrasion,  scratch,  or  pimple 
must  be  protected  by  a  small  piece  of  pink  mackintosh  or  oiled  silk. 
The  properly  prepared  electrode,  whether  clay,  flannel,  or  gelatine,  is 
now  to  be  carefully  laid  on  the  abdominal  surface  so  that,  in  the 
case  of  flannel,  there  are  no  creases,  and  that  no  part  of  it  rests  on 
the  bony  edge  of  the  ilium.  The  pad  must  then  be  pressed  firmly 
down,  the  connection  to  the  other  electrode  made,  and  the  blanket  drawn 
up  over  the  body.  The  patient  is  then  requested  to  place  both  hands  on 
the  pad,  and  to  x>ress  evenly  and  gently,  so  as  to  ensure  good  contact. 
The  galvanometer  will  now  indicate  2  to  5  m.a.  according  to  the  electro- 
motive force  of  the  battery  and  the  resistance  of  the  rheostat.  This  current 
is  of  course  not  appreciable  by  the  patient.  The  various  binding  screws 
should  now  be  examined  and  tested  to  make  certain  of  their  being  firmly 
adjusted.  The  slide  of  the  highest  rheostat  is  now  slowly  moved  so  as 
to  reduce  the  resistance,  the  patient's  face  and  the  galvanometer  being 
carefully  watched.  Then  the  next  slide  is  even  more  slowly  moved,  and, 
if  iieed  be,  the  third,  until  the  limit  of  tolerance  is  reached,  or  until  the 
galvanometer  shows  that  the  necessary  current  strength  is  passing.  If 
great  pain  is  complained  of  before  this  degree  is  reached,  inquiry  should  be 
made  if  it  is  general  all  under  the  pad,  or  concentrated  at  one  or  more 
points.  If  the  former,  the  current  should  be  reduced  for  a  little,  when  it 
will  generally  be  found  that  the  sensation  of  burning  disappears,  and  the 
current  may  again  be  gradually  increased.  If  the  pain  be  confined  to  one 
or  more  spots  it  is  probably  due  to  some  tender  area  of  skin,  or  to  some 
irregularity  in  the  application  of  the  pad;  in  this  case  the  current 
must  be  reduced  by  introducing  the  full  resistance  of  the  rheostat,  and 
the  pad  removed  and  examined.  A  particle  of  salt  which  has  escaped 
solution  may  be  the  cause  of  very  severe  local  pain.  If  this  be  over- 
looked, and  the  current  kept  on,  a  small  but  very  painful  ulcer  may  be 
formed,  which  will  take  months  to  heal.  The  duration  of  the  applica- 
tion is  reckoned  from  the  moment  at  which  the  proper  current  strength 
is  attained:  it  is  generally  continued  for  5  to  10  minutes.  At  the 
conclusion  of  tliis  time  the  current  is  to  be  gradually  and  slowly  reduced, 
beginning  with  the  lowest  slide  of  the  rheostat,  and  ending  with  the 
highest.  When  the  full  resistance  has  been  introduced  the  internal 
electrode  shoul'l  !)'■,  witlulrawn,  and  the  pad  rcnxjvcul  from  the  abdomen, 


THE   ELECTRICAL    TREATMENT    OF  DISEASES    OF   WOMEN    315 

which  is  sponged  with  warm  water  and  dried.  The  patient  should  then 
remain  lying  ou  this  or  another  couch  for  a  quarter  of  an  hour :  after 
this  she  should  put  on  her  clothes.  It  is  Avell  to  advise  patients, 
after  the  hrst  few  applications,  to  keep  to  a  couch  for  the  rest  of  the 
day ;  and  also  on  any  other  occasion,  if  any  pain  or  red  discharge  follow 
the  application,  she  should  be  advised  to  go  to  bed,  or  at  least  to  lie 
down  for  the  evening.  It  is  also  very  important  that  in  the  course  of 
an  hour  or  two  after  each  application  the  vagina  should  be  douched 
with  carbolic  lotion.  When  puncture  of  a  fibroid  tumour  or  of  an  in- 
flammatory deposit  has  been  practised  special  precautions  are  necessary. 
These  Avill  be  discussed  later. 

III.  The  Mode  of  Action  of  the  Continuous  Current. —  It  will  now 
be  convenient  to  consider  shortly  the  effects  on  the  tissues  produced  by 
the  transmissions  of  continuous  currents  through  them  by  means  of 
metallic  electrodes.  This  will  be  best  understood  if  we  study,  in  the 
first  place,  the  effect  of  the  passage  of  the  current  through  a  piece  of 
dead  tissue  —  say  a  piece  of  beef.  A  small  block  of  fresh  beef  is  placed 
on  a  dish,  and  into  it  tAvo  steel  sewing  needles  are  inserted  at  a  distance 
of  an  inch  from  each  other.  One  of  these  is  connected  to  the  positive 
and  the  other  to  the  negative  pole  of  a  battery,  and  a  current  of,  say,  50 
]u.a.  is  transmitted.  The  folloAving  things  will  be  observed :  1st,  in  a 
few  seconds  a  frothy  effervescence  will  appear  round  the  negative  needle, 
while  the  tissue  will  shrink  and  condense  round  the  positive  needle ;  2nd, 
if,  at  the  end  of  a  few  minutes,  the  negative  needle  be  gently  pulled,  it 
will  come  away  Avithout  difiiculty,  leaving  an  aperture  a  good  deal  Avider 
than  its  own  thickness.  This  aperture  opens  into  a  sinus  Avhich  is  filled 
with  a  soft  frothy  scum ;  ord,  if  the  positive  needle  be  similarly  pulled, 
it  Avill  not  come  aAvay  Avithout  considerable  traction,  and  Avill  leave  a 
small  orifice  with  a  dense,  firm  outline.  4th,  On  examination  the  neg- 
ative needle  Avill  be  found  quite  bright,  Avhile  the  positive  needle  Avill 
be  dulled  and  slightly  corroded;  5th,  if  the  piece  of  meat  be  now  care- 
fully cut  open,  so  as  to  expose  the  channels  formed  by  the  needles,  it  Avill 
be  found  that  the  track  of  the  negative  needle  is  surrounded  by  a  softened 
loose  area  of  disorganised  tissue,  Avhile  the  tract  of  the  positive  is 
surrounded  by  a  condensed  area  much  smaller  than  that  round  the 
negative  needle,  it  is,  moreover,  paler  in  colour,  and  cuts  Avitli  a  some- 
what gritty  sensation ;  (ith,  if  the  surfaces  so  exposed  are  tested  Avith 
litmus  paper,  it  Avill  be  found  that  on  the  negative  side  an  alkaline,  and 
on  the  positive  side  an  acid  reaction  is  given. 

Similar  phenomena  are  seen  as  the  result  of  the  action  of  such 
a  current  on  the  albumin  of  an  egg.  If  the  whites  of  two  eggs  be 
placed  in  a  glass  beaker,  and  a  current  of  20-30  m.a.  be  passed 
through  them  by  means  of  steel  needles,  a  loose  flocculent  coagulum 
Avill  form  round  the  negative  needle.  After  a  time  this  disintegrates  and 
floats  through  the  rest  of  the  fluid,  leaving  the  needle  quite  clean  and 
bright.  Round  the  positive  needle  a  dense  compact  clot  is  formed  Avliich 
firmly  adheres  to  it,  and  can  be  lifted  out  of  the  vessel  by  means  of  it. 


31 6  SYSTEM  OF  GYNECOLOGY 

On  examination  by  test-paper  the  positive  clot  "svill  be  found  markedly 
acid,  and  the  negative  markedly  akaline. 

These  changes  constitute  part  of  the  phenomena  of  electrolysis  ;  and 
experiment  has  shown  that  under  similar  conditions  identical  results  are 
produced  in  the  tissues  of  the  living  body.  Briefly  stated,  we  find  then 
that  round  the  metallic  surface  of  the  negative  ])o\q 2^hysical  disintegration 
of  tissue  results  with  a  chemical  alkaline  react  ion,  ^vhile  round  the  positive 
pole  a  physical  condensation  of  tissue  results  luith  a  chemiccd  acid  reaction. 

So  far  as  the  quantitative  aspects  of  the  case  are  concerned  Ave  must 
keep  in  mind  that  the  amount  of  tissue  broken  up  at  the  two  poles  is, 
chemically  speaking,  identical.  The  basic  products  set  free  at  the  negative 
are  chemically  equivalent  to  the  acid  products  set  free  at  the  positive 
electrode. 

In  the  present  state  of  our  knowledge  it  is  impossible  to  state 
precisely  the  chemical  nature  of  the  products  of  electrolytic  decom- 
position at  either  pole :  they  are  highly  complex.  Among  them, 
however,  we  may  readily  detect  a  certain  amount  of  caustic  soda 
and  potash  at  the  negative,  and  of  chlorine  at  the  positive  pole.  To 
what  extent  the  influence  of  these  chemical  substances  may  be  credited 
with  the  production  of  the  peculiar  coagula  found  at  the  respective 
poles  is  a  matter  of  some  doubt,  in  spite  of  the  fact  that  Apostoli  and  his 
immediate  followers  hold  that  they  explain  the  wide  difference  of  the 
condition  of  the  tissues  observed.  On  this  account  Apostoli  terms  the 
action  of  the  positive  pole  "  acid  galvano-caustic  " ;  and  of  the  negative 
"  alkaline  galvano-caustic."  Our  ignorance  of  the  precise  nature  of  the 
chemical  and  vital  changes  induced  by  electrolysis  of  these  complex  bodies 
scarcely  justifies  this  assumption ;  and  further  investigation  is  necessary 
to  explain  the  marked  difference  between  the  influence  of  these  poles. 

It  seems  safer  in  the  meantime  to  accept  simply  that  the  difference  in 
the  action  exists ;  and,  in  cases  where  we  seem  to  require  a  loose  disin- 
tegration of  tissue,  to  employ  the  negative  pole ;  and  in  others,  where  we 
seem  to  require  an  "  astringent "  or  condensing  eft'ect,  to  resort  to  the 
positive  pole.  In  other  words,  it  is  better  at  present  in  our  employment 
of  these  currents  to  trust  to  an  empirical  knowledge  of  the  effects  i)ro- 
duced,  than  to  attempt  to  guide  our  methods  by  an  assumed  knowledge 
of  the  way  in  which  those  effects  are  produced. 

In  addition  to  the  electrolytic  effect  another  influence  of  the  con- 
tinuous current  is  claimed  by  certain  authors;  this  is  termed  the 
"  interpolar  ett'ect."  By  this  is  meant  an  assumed  influence  of  the 
current  upon  the  tissues  lying  between  the  electrodes.  It  is  practically 
assumed  that  the  passage  of  the  current  produces  a  certain  influence, 
disintegrating  orotherwise,  upon  the  moleculesof  the  tissue  which  liein  its 
path  Vjfttween  one  electrode  and  another.  To  this  supposed  interpolar 
effef;t  is  attributed  a  great  part  of  the  diminution  in  the  Ijidk  of  fibroid 
tumours  and  cellulitic  deyjosits  wliicli  is  occasionally  iiuit  with  in  our 
experience.  Now,  it  is  adinitted  that  there  is  no  physical  evidence  for 
the  decomposition  of  the  solniiou  of  a  salt  by  a  galvanic  current  save  in 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    317 

the  vicinity  of  the  electrodes.  The  products  of  the  decomposition 
appear  round  the  electrodes,  and  so  far  as  any  direct  evidence  is  con- 
cerned there  is  no  proof  that  any  change  occurs  in  the  fluids  between 
these  regions.  Still  less  is  there  any  evidence  that  electrolytic  decom- 
position takes  place  in  such  a  mass  as  that  of  a  fibroid  tumour  away  from 
the  seat  of  the  electrodes  in  contact  Avith  it.  Any  so-called  experimental 
proof  which  has  been  advanced  in  favour  of  the  existence  of  interpolar 
decomposition  can  be  readily  explained  on  other  grounds ;  and  we  may 
take  it  that  there  is  no  proof  of  any  electrolytic  decomposition  occur- 
ring anywhere  except  round  the  metallic  electrodes. 

There  is  abundant  clinical  evidence,  hoAvever,  that  the  passage  of  a 
current  through  the  pelvis  may  have  other  than  directly  electrolytic 
effects.  For  example,  it  is  a  matter  of  common  experience  that,  after 
two  or  three  applications  of  a  fairly  powerful  current  to  a  uterine  fibroid, 
the  bulk  of  it  will  be  appreciably  diminished.  This  immediate,  but  in 
many  cases  temporary  effect  is  oftenest  produced  when  the  positive  pole 
is  applied  to  the  interior  of  the  uterus ;  and  it  appears  to  be  due  to 
a  stimulation  of  the  muscular  fibres  of  the  uterus  and  tumour  by  the 
ciirrent,  which  results  in  a  vigorous  contraction  and  expulsion  of  a  large 
amount  of  the  blood  contained  in  these  structures,  and  a  consequent 
diminution  of  their  bulk.  That  this  may  have  an  important  effect  on  the 
nutrition  and  growth  of  such  a  tumour  seems  very  likely,  and  that  its 
repeated  reproduction  may  ultimately  induce  a  progressive  atrophy  of 
such  a  neoplasm  is  no  less  probable.  That  this  is  the  action  of  the 
current  in  many  of  these  cases  is  also  borne  out  by  the  fact  that  bulky 
and  somewhat  soft  fibroids,  after  a  few  applications,  often  show  a 
marked  diminution  in  bulk ;  while  at  the  same  time  they  become  firm 
and  condensed  to  external  manipulation.  Further,  during  this  process 
of  shrinkage,  we  may  notice  that  large  quantities  of  watery  discharge 
are  constantly  escaping  from  the  uterine  cavity. 

A  second  effect,  which  one  may  often  observe  in  cases  under  treatment, 
is  the  production  of  a  sense  of  improved  Avell-being  which  frequentl}'^  is 
felt  almost  from  the  first.  Every  one,  who  has  had  an  experience  of 
any  extent  in  the  treatment  of  pelvic  diseases  by  electricity,  must  have 
noticed  how  often  the  patient  expresses  herself  as  greatly  benefited  by 
the  treatment  long  before  any  definite  change  can  be  detected  in  the  local 
condition.  So  manifest  and  constant  is  this  effect,  that  it  would  almost 
appear  that  these  electric  currents  in  some  way  induce  an  improved 
nutrition  and  a  general  exaltation  of  function  in  which  the  nervous 
system  especially  participates. 

IV.  The  therapeutic  application  of  electricity,  to  those  diseases  of  the 
female  pelvic  organs  in  which  experience  has  shoAvni  that  beneficial 
results  have  followed  its  use,  is  now  to  be  considered. 

Stenosis.  —  A  contracted  state  of  the  os  externum  or  of  the  cervical 
canal,  Avhether  congenital  or  acquired,  can  be  successfully  treated  by 
electricity.  The  symptoms  associated  with  this  condition  are  usually 
dysmenorrhoea  and  sterility.     In  congenital  conditions  there  is  often, 


3i8  SYSTEM   OF  GYNECOLOGY 

though  by  no  means  always,  an  imperfect  development  of  the  uterus  and 
ovaries ;  and  in  these  cases,  of  course,  the  main  object  is  to  relieve  the 
dysmenorrhoea.  These  conditions  can  no  doubt  be  treated  in  most  cases 
by  dilatation  on  one  or  other  of  the  well-known  methods.  This,  to  be 
satisfactory,  involves  the  use  of  an  anaesthetic,  for  when  the  dilatation  is 
carried  to  the  necessary  extent  the  pain  produced  is  very  great.  Further, 
it  is  a  matter  of  common  experience  that  there  is  a  tendency  for  the  pain 
to  recur  after  several  months  of  painless  menstruation ;  so  that,  in  order 
to  relieve  the  menstrual  pain,  the  repetition  of  the  operation  to  a  certain 
degree  is  required  from  time  to  time. 

Considerable  experience  with  both  methods  seems,  however,  to  show 
a  distinct  advantage  in  favour  of  the  electrical  treatment  for  these 
conditions.  This  treatment  is  practically  painless;  it  involves  no  in- 
terference with  ordinary  duties  or  occupations,  and  its  results  in  my 
experience  have  been  more  permanent  and  more  completely  satisfac- 
tory than  those  of  forcible  dilatation. 

The  mode  of  treatment  is  as  follows :  —  The  ordinary  platinum  sound 
is  employed  as  the  internal  electrode.  With  a  little  care  this  can  be 
introduced  into  the  canal  without  any  previous  dilatation ;  but,  if  need 
be,  a  jSTo.  1  or  jSTo.  2  Hegar  dilator  may  be  passed  first. 

The  sheath  is  carefully  pushed  up  against  the  os,  and  this  electrode  is 
connected  to  the  negative  pole ;  the  abdominal  pad  is  now  applied  and 
connected  to  the  positive  pole,  and  a  current  of  from  50  to  80  m.a.  is 
slowly  turned  on.  This  should  be  continued  for  five  minutes,  and  then 
taken  off  gradually.  This  application  should  be  made  twice  a  week  for 
eight  or  ten  times.  Unless  an  application  takes  place  very  near  the 
expected  time  of  menstruation  there  is  no  need  of  any  special  restriction 
on  the  patient's  movements.  If  it  happens  within  a  day  or  two  of  the 
menstrual  onset  she  should  rest  for  some  time  afterwards. 

After  two  or  three  sittings  it  will  be  found  that  the  canal  is  much 
more  patent.  It  is  advisable  then  to  employ  the  thick  sound,  taking 
care  always  that  it  is  not  inserted  too  far  into  the  cavity ;  its  point 
•should  just  pass  through  the  os  internum. 

The  relief  given  to  the  dysmenorrhoea  is  almost  always  immediate ;  if 
■only  two  or  three  applications  have  been  made  before  a  period  sets 
in  this  period  will  be  almost  painless.  As  a  rule  ten  applications 
■  of  the  strength  indicated  are  enough.  When  the  cervix  is  at  first 
very  sensitive,  owing  to  the  presence  of  an  endocervicitis  or  an  endo- 
metritis, the  patient  may  not  be  able  to  bear  such  current  strengths ;  in 
these  cases  it  is  better  to  begin  with  the  use  of  the  anode  internally, 
using  a  current  strength  well  within  toleration.  After  a  few  applications 
it  will  be  found  that  the  full  kathodal  strength  can  be  used  without 
inconvenience. 

Endometritia.  —  The  great  majority  of  cases  of  chronic  endometritis 
nndoubtedly  yield  to  the  various  means,  otlier  tlia,n  electrical,  at  the 
disposal  of  the  gynaecologist.  These  have  tht;  advantage  of  occupying 
less  time,  a  matter  of  considerable  importance  to  many  patients.     The 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    319 

simpler  measures,  such  as  the  application  of  caustics  like  carbolic  acid  or 
iodine,  to  the  endometrium,  if  done  with  reasonable  skill  and  care,  are 
practically  devoid  of  danger.  But  it  is  only  in  the  milder  cases  that  we 
can  expect  such  measures  to  effect  a  cure.  The  more  efficient  and  more 
drastic  procedure  of  curettage  is  now  found  necessary  in  a  large  number 
of  cases;  and  it  is  useless  to  deny  that  this  method,  even  in  experienced 
hands,  is  associated  with  very  considerable  danger :  the  danger  may  be 
minimised  by  skill  and  care,  but  it  cannot  be  entirely  eliminated.  It  is, 
accordingly,  as  an  alternative  to  curettage  that  the  advantage  of  electrical 
treatment  appears ;  for,  with  the  simplest  precautions,  this  method  is 
free  from  danger.  Not  only  so,  but  the  experience  of  a  very  considerable 
number  of  cases  has  shown  that  it  will  often  cure  when  repeated  curetting 
has  failed  to  produce  any  permanent  benefit.  I  am  convinced  that 
electrical  treatment  will  cure  any  case  curable  by  curetting,  and  will  also 
cure  many  cases  that  curetting  cannot  cure.  Against  the  length  of  time 
that  it  occupies  we  may  confidently  put  the  entire  freedom  from  danger. 
Still,  I  do  not  advocate  its  use  in  all  cases  of  endometritis.  The  time 
occupied  by  it,  which  is  not  less  than  two  and  often  as  long  as  three  or 
four  months,  is  a  serious  difficulty,  and  one  which  renders  the  method  im- 
practicable for  a  considerable  number  of  patients.  In  the  simpler  and 
more  recent  cases  the  cauterisation  of  the  endometrium  is  easy  and  effective; 
inthemore  chronic  and  persistent  cases  I  should  certainly  advise  thorough 
curetting.  If  this  is  to  be  effective  the  result  will  show  itself  in  a  sliort 
time ;  but  if  not,  and  if  any  of  the  symptoms  return,  I  do  not  hesitate  to 
advise  electrical  treatment  as  being  much  more  likely  to  produce  a  per- 
manent cure  than  any  number  of  subsequent  applications  of  the  curette. 

The  symptoms  of  chronic  endometritis  are  chiefly  leucorrhoea,  haem- 
orrhage, and  local  discomfort;  and  the  predominance  of  one  or  other 
of  these  in  any  given  case  forms  a  sound  gi;ide  to  the  proper  mode  of 
electrical  treatment. 

Without  going  into  a  detailed  consideration  of  the  pathological 
changes  in  the  endometrium  in  the  various  kinds  of  this  disorder,  it  may 
be  advisable  to  recall  the  fact  that,  in  the  glandular  variety,  we  have  a 
characteristic  increase  of  the  gland  elements  of  the  endometrium,  accom- 
panied by  thickening  of  the  whole  membrane,  and  characterised  by  a 
more  or  less  profuse  flow  of  a  discharge  which  may  be  watery,  creamy,  or 
greenish  :  in  the  hemorrhagic  variety  the  membrane  is  greatly  thickened, 
thrown  into  elevations,  and  especially  characterised  by  a  great  increase  of 
the  vascular  constituents  of  the  structure.  A  third  variety,  characterised 
by  a  profuse  flow  of  muco-pus,  is  distinguished  by  the  development  of 
granulations  composed  of  an  embryonic  tissue.  This  last  variety  seems 
to  be  somewhat  rare ;  the  great  majority  of  the  cases  fall  in  the  first 
two  classes.  It  should  be  kept  in  mind  that  practically  in  every  case  of 
endometritis  the  uterus  is  enlarged  ;  the  tissues  of  the  wall  seem  swollen. 
soft,  and  boggy,  and  the  organ  is  usually  niobile,  readily  falling  to  one  or 
other  side  of  the  pelvis  with  the  inclination  of  the  body. 

Very  often  the  os  is  patulous ;  this  is  generally  the  case  with  the  os 


320  SYSTEM  OF  GYNECOLOGY 

externum,  but  in  a  certain  number  of  cases  the  os  internum  is  not  larger 
than  usual,  and  admits  nothing  thicker  than  the  ordinary  sound  without 
being  stretched. 

The  amount  and  kind  of  the  pelvic  distress  are  very  variable.  In 
some  cases  there  may  be  little  or  none;  in  others  there  may  be  more  or 
less  constant  discomfort,  amounting  at  times  to  severe  pelvic  pain.  In 
most  there  is  an  unpleasant  backache  or  feeling  of  weariness  and  fatigue 
which  greatly  interferes  with  the  performance  of  ordinary  duties. 

The  details  of  the  treatment  of  chronic  endometritis  vary  with  the 
nature  of  the  conditions  to  be  dealt  with.  Attention  must  be  given  to 
the  special  s^^mptoms  present  in  each  case ;  as  we  have  seen  these  are 
generally  pain,  leucorrhoea,  and  haemorrhage.  It  is  generally  laid  down  as 
a  guiding  rule  that  if  haemorrhage  be  a  prominent  feature  the  positive  pole 
should  be  used  internally,  and  when  this  is  not  the  case  that  the  internal 
electrode  should  be  negative.  There  seems  no  doubt  at  all  as  to  the 
propriety  of  the  use  of  the  positive  pole  in  haemorrhagic  cases  ;  the  "  as- 
tringent ''  and  haemostatic  influence  of  it  is  well  known,  and  the  results 
on  the  first  menstrual  period  after  the  beginning  of  treatment  are  usually 
very  striking.  Not  only  does  it  seem  effectually  to  destroy  the  haemor- 
rhagic endometrium,  but  it  seems  in  a  very  definite  way  to  diminish  the 
bulk  of  the  whole  organ,  during  and  for  some  time  after  each  application ; 
as  if  it  caused  an  emptying  of  the  distended  vessels  in  its  walls.  On  the 
other  hand,  the  wisdom  of  the  routine  use  of  the  negative  pole  internally, 
in  all  cases  of  a  marked  leucorrhoeal  type,  is  by  no  means  so  evident.  In 
these  cases  the  endometrium  is  no  doubt  thickened  by  an  increase  of  the 
glandular  or  connective  tissue  elements  of  the  structure,  and  accordingly 
the  negative  pole  is  employed  on  account  of  its  supposed  destructive 
action  on  the  tissues.  It  is  assumed,  in  fact,  that  "  electrical  curettage  " 
is  more  effectually  performed  by  the  negative  pole.  This,  however,  is  by 
no  means  clearly  proved.  ISTo  doubt  the  electrolytic  results  of  the  kathode 
are  more  bulky,  because  more  loosely  held  together;  but  the  actual 
amount  of  tissue  destroyed  is  not  necessarily  greater.  The  affected  area 
round  the  anode  seems  less  than  that  around  the  kathode,  because  the 
affected  tissue  in  the  former  case  shrinks  more  than  in  the  latter;  but 
the  tissue  round  the  anode  is  as  thoroughly  devitalised  as  that  round  the 
kathode.  As  a  matter  of  fact  the  influence  of  both  poles  is,  chemically 
and  quantitatively  speaking,  equivalent ;  but  the  anodal  application  has 
this  advantage  over  the  kathodal,  that  it  tends  most  effectively  to  restrain 
haemorrhage.  The  destruction  of  the  diseased  endometrium  must  often 
i-esult  in  the  exposure  of  a  more  or  less  vascular  surface.  Every  one 
knows  how  some  of  these  leucorrhoeal  wombs  bleed  during  the  use  of  an 
ordinary  curette.  Accordingly,  after  the  use  of  the  negative  electrode  it 
is  not  uncommon  to  find  patients  losing  blood  for  some  days  in  greater  or 
less  amount ;  and  if  a  yjcriod  comes  on  after  but  one  or  two  applications 
the  menorrhagia  is  often  considerable,  and  this  in  patients  in  whom 
haemorrhage  had  not  previously  been  a  prominent  symptom.  Now  with 
the  anode  used  internally  this  is  very  seldom  the  case.     As  a  rule  in 


THE   ELECTRICAL    TREATMENT   OF  DISEASES    OF    WOMEN    321 

these  cases  there  is  a  little  red  or  reddish  discharge  ou  the  evening  of  the 
sitting,  or  perhaps  for  an  hour  or  two  next  day;  but  the  quantity  is  incon- 
siderable, and  never  amounts  to  hseniorrhage.  When  I  iirst  began  to 
employ  electricity  for  the  treatment  of  endometritis  I  always  employed 
the  negative  pole ;  and  to  combat  the  haemorrhage,  used  to  enjoin  on  the 
patient  the  necessity  of  going  to  bed  and  using  a  hot  douche,  or  taking 
some  ergot  every  day  while  the  early  part  of  the  treatment  lasted :  but 
in  spite  of  this  the  exhaustion  of  the  patient  by  persistent  blood  loss  was 
a  serious  matter.  Such  complications  are  entirely  avoided  by  the  use  of 
the  anode. 

Moreover,  the  anode  has  another  advantage  in  the  treatment  of  these 
cases.  A  painful  condition  of  the  pelvic  organs  constitutes  a  marked 
feature  in  many  cases  of  endometritis,  which  pain  may  be  due  to  the 
inflamed  state  of  the  uterus  or  to  altered  conditions  of  the  tubes, 
ovaries,  peritoneum,  or  parts  around ;  in  these  cases  the  negative  pole  is 
very  badly  borne.  The  kathode,  when  applied  to  normal  surfaces  such 
as  the  healthy  skin,  is  far  more  irritating  to  sensory  nerves  than  the 
anode.  This  sensory  effect  is  greatly  exaggerated  in  inflamed  structures, 
and  accordingly  it  is  difficult  or  impossible  for  many  patients  to  tolerate 
a  current  of  sufficient  strength  for  any  length  of  time  if  the  kathode  is 
used  internally.  On  these  grounds,  then,  I  should  strongly  advise  that, 
in  all  cases  of  endometritis,  whatever  the  prominent  symptoms  may  be, 
the  internal  pole  should  be  anodal,  at  any  rate  at  the  commencement  of 
treatment.  In  this  way  haemorrhage  will  be  checked,  and  larger  and 
therefore  more  efficient  currents  will  be  more  easily  borne. 

The  mode  of  making  the  application  does  not  materially  differ  from 
that  of  which  a  general  description  has  been  already  given.  One  or  two 
points,  however,  require  notice.  For  the  first  four  or  five  applications  it 
is  advisable  to  employ  the  ordinary  platinum  sound-electrode,  exposing 
as  much  of  the  metal  as  corresponds  to  the  length  of  the  uterine 
canal.  In  this  way  the  whole  cavity  is  brought  under  the  influence  of 
the  current.  The  handle  of  the  sound  may  be  moved  slightly  now  and 
then  during  the  sitting  in  order  to  bring  the  platinum  in  contact  with 
different  parts  of  the  endometrium.  After  four  or  five  applications  have 
been  made  by  this  instrument  the  thick,  short  platinum  sound,  or 
Apostoli's  carbon  electrode  should  be  used,  the  active  part  being  shifted 
down  the  cavity  length  by  length,  either  at  each  sitting  or  on  consecutive 
sittings.  In  this  way  the  current  density  is  greatly  increased,  and  is 
brought  to  bear  on  each  segment  of  the  cavity  in  succession. 

A  very  careful  preliminary  bimanual  examination  shoiild  be  made 
in  order  to  determine  the  exact  position  of  the  os  and  the  lie  of  the 
uterine  body ;  and  in  passing  the  electrode  the  greatest  care  should  be 
exercised  so  as  to  excite  as  little  pain  as  possible.  If  pain  be  caused  at 
this  stage  it  will  seriously  interfere  with  the  toleration  of  a  suitable 
current  strength.  When  the  sound  is  fully  introduced  the  sheath  should 
be  pushed  well  up  into  the  cervix  to  protect  it  from  the  action  of  the 
current :  the  cervix  is  sometimes  highly  sensitive,  and  it  is  better,  at  first 

Y 


322  SYSTEM  OF  GYNECOLOGY 

at  any  rate,  to  concentrate  the  action  on  the  endometrium  proper. 
When  tlie  sound  is  properly  placed  and  connected,  the  application  of  the 
abdominal  pad  requires  some  attention.  It  should  be  large  so  as  to 
diminish  the  skin  resistance  as  much  as  possible :  if,  however,  it  is 
known  that  one  ovary  is  inflamed,  or  that  one  side  of  the  pelvis  is  more 
sensitive  than  another,  the  pad  must  be  shaped  so  as  to  avoid  this  region. 
To  do  this,  and  yet  to  obtain  a  sufficient  surface,  it  may  be  advisable  to 
shift  the  pad  well  on  to  the  epigastrium,  or  as  high  up  on  the  thorax  as 
the  mammae  will  permit.  Some  have  recommended  that  the  pad  be 
placed  on  the  back,  or  that  an  auxiliary  pad  be  used  there ;  but  it  is 
difficult  to  get  good  contact  on  the  back  with  the  patient  in  the  dorsal 
position,  and  a  little  management  will  enable  us  to  get  all  the  surface  we 
want  on  the  anterior  aspect  of  the  body.  The  current  employed  should 
be  moderate  at  first ;  if  50  m.a.  can  be  borne  on  the  first  occasion  we 
should  rest  content.  This  may  be  kept  up  for  eight  minutes  or  so  and 
then  gradually  reduced.  On  subsequent  occasions  the  current  must  be  in- 
creased; this  can  be  done  without  difficulty  if  care  be  taken,  until  by 
the  eighth  or  ninth  sitting  as  much  as  150  or  170  m.a.  can  be  borne.  I 
am  of  opinion  that  in  this  group  of  cases  a  much  stronger  current  is 
required  than  in  some  other  groups — bleeding  fibroids,  for  example.  To 
judge  from  the  recent  writings  on  this  subject,  most  operators  have  aban- 
doned the  use  of  the  very  powerful  currents — 250  m.a.  and  up  wards — first 
recommended  by  Apostoli ;  and  in  this  decision  I  quite  agree  with  them. 
But,  while  excellent  results  can  be  obtained  in  the  treatment  of  bleed- 
ing fibroids  by  the  use  of  currents  of  only  100  m.a.  or  even  less,  I  be- 
lieve the  best  results  in  cases  of  endometritis,  whether  haemorrhagic  or 
leucorrhceal,  can  be  got  only  by  the  use  of  currents  a  good  deal  stronger 
than  this.  Hence  the  importance  of  taking  all  the  precautions  possible 
to  favour  the  toleration  of  a  high  current,  —  these  being,  as  I  have  said, 
the  use  of  the  anode,  great  care  in  introducing  the  sound,  the  protection  of 
the  cervix,  and  the  proper  application  of  the  external  electrode.  A 
douche,  both  before  and  after  the  application,  must  be  insisted  on ;  and 
if  pain  persist  the  patient  should  go  to  bed  and  repeat  the  douche  (at 
105°)  in  the  course  of  the  evening.  If  there  be  no  pain  the  avoidance 
of  any  undue  exertion  is  all  that  need  be  exacted.  The  application 
should  1)6  made  twice  a  week.  The  first  three  days  of  the  menses  should 
be  avoided,  but  after  that  treatment  should  be  resumed.  As  to  the 
number  of  applications  required  much  will  depend  on  the  circumstances 
of  each  case.  If  the  patient  is  regular  in  attendance  and  can  bear  a 
medium  current,  fifteen  to  twenty -five  sittings  will  suffice ;  but  more  will 
be  required  in  cases  where  these  conditions  cannot  be  ol>tained.  After 
twenty-five  applications  have  been  made  it  is  advisable  to  stop  for  a 
month,  watching  the  symptoms;  if  they  seem  then  to  increase  a  few  more 
applications  should  be  made,  but  I  have  not  met  with  any  case  in  which 
twenty-five  consecutive  applications  of  averag<*  sti'cngth  failed  to  effect 
a  cure.  In  cases  in  which  pain  is  a  prominent  feature,  and  in  which  the 
pain  is  increased  by  the  application  of  the  continuous  current,  and  continues 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    323 

for  some  time  afterwards,  great  advantage  will  be  gained  by  the  use  of 
the  "  faradic  "  or  induced  current.  This  application  is  made  as  follows  : 
—  the  continuous  current  having  been  applied,  as  above  directed,  to  the 
full  tolerance  of  the  patient  for,  say  five  or  six  minutes,  the  current  is 
slowly  reduced,  and  when  zero  has  been  reached,  the  electrodes  are  con- 
nected to  the  terminals  of  the  secondary  coil,  which  should  have  as  many 
turns  as  are  available.  The  hammer  should  be  set  to  give  the  most  rapid 
interruptions  possible.  The  apparatus  is  started  with  the  current  at 
its  weakest,  and  gradually  increased  until  the  patient  begins  to  feel  a 
sensation  of  numbness  in  the  pelvis ;  after  which  time  it  may  be  con- 
tinued for  three  or  four  minutes  and  then  stopped.  In  most  cases  this 
completely  removes  any  pain  which  may  have  been  caused  by  the  con- 
tinuous current. 

During  a  course  of  treatment  such  as  this  the  patient  should  be 
advised  as  to  the  regulation  of  her  diet  and  the  action  of  the  bowels ; 
and  she  should  be  encouraged  in  the  use  of  reasonable  exercise.  As  was 
previously  noticed,  nothing  is  more  remarkable  in  these  cases  than  the 
almost  immediate  effect  this  treatment  seems  to  have  on  the  general  well- 
being  of  the  patient.  From  the  first  the  sense  of  depression,  which  is  so 
common  in  this  disorder,  begins  to  lighten.  Exercise  becomes  less  and 
less  a  burden,  appetite  and  circulation  manifestly  improve,  and  the  bowels 
either  begin  to  act  regularly  and  spontaneously,  or  do  so  under  much 
less  artificial  stimuli  than  they  have  previously  required.  This  sense  of 
improvement  greatly  lightens  the  tedium  of  the  treatment,  encourages 
the  patient,  and  enables  her  to  tolerate  increasing  and  hence  more  effec- 
tive current  strengths. 

One  word  by  way  of  caution.  During  the  whole  course  of  treatment, 
but  especially  towards  the  end  of  it,  sexual  intercourse  must  be  forbidden. 
As  the  patient  improves  conception  may  occur,  say  after  a  menstrual 
period,  during  and  subsequent  to  which  there  may,  for  some  reason,  have 
been  a  somewhat  longer  cessation  of  the  applications  than  usual.  "When 
these  are  resumed  it  is  more  than  likely  that  abortion  may  be  induced  by 
the  first  application  of  the  current.  I  have  in  my  records  two  cases 
where  profuse  and  persistent  heemorrhage,  which  I  can  account  for  in 
no  other  way,  followed  an  application.  Indeed  in  one  case  decidual 
shreds  came  away  for  a  long  time  afterwards.  In  this  case,  owing  to 
special  circumstances,  the  application  had  been  in  abeyance  for  nearly  a 
month. 

Subinvolution.  —  A  group  of  cases  in  which  excellent  results  are 
obtained  by  the  use  of  electricity  are  those  in  which,  after  a  compara- 
tively recent  pregnancy,  the  normal  involution  of  the  uterus  has,  by 
some  cause  or  other,  been  checked,  and  it  remains  large,  congested,  and 
soft.  This  is,  of  course,  most  frequently  seen  after  neglected  or  badly 
managed  abortions  occurring  in  the  early  months;  and  the  condition  is 
one  which,  as  every  gynecologist  well  knows,  is  often  the  precursor  of  a 
whole  train  of  morbid  phenomena,  organic  as  well  as  functional.  Let  us 
take  a  typical  case:  an  abortion  has  occurred  at,  say,  the  third  or  fourth 


324  SYSTEM  OF  GYNECOLOGY 

mouth;  a  few  days  afterwards  the  patient  gets  up,  the  haemorrhage 
having  barely  ceased ;  the  next  period  comes  on  in  about  three  weeks, 
and  is  so  profuse  that  the  woman  maybe  compelled  to  return  to  bed  for 
a  while ;  the  hasmorrhage  ceases,  she  resumes  her  duties  with  the  same 
result  —  a  premature  and  profuse  menstruation.  Such  a  condition  as 
this  may  continue  for  some  months,  the  patient  suffering  seriously  from 
the  losses,  from  an  intermenstrual  leucorrhoeal  discharge,  and  from 
constant  and  increasing  pelvic  distress.  If  the  patient  now  comes 
under  observation  we  find  a  large,  soft  uterus,  often  retroflexed  and  re- 
troverted,  with  a  patulous  os  and  some  tenderness  on  pressure.  The 
sound  may  pass  3|-  to  5  inches,  and  it  is  felt  also  that  the  walls  are  con- 
siderably thickened.  With  every  care  it  may  be  impossible  to  avoid  pro- 
ducing some  haemorrhage  on  passing  the  sound.  The  uterus  may  be  found 
tender,  and  not  unfrequently  the  ovary  on  one  or  other  side  is  prolapsed. 
Usually  the  rectum  is  loaded,  or  at  any  rate  large  doses  of  purgatives 
are  required  to  produce  an  evacuation.  We  have  to  deal  here  with  the 
first  or  congestive  stage  of  a  chronic  metritis,  which  may  be  associated 
ultimately  with  the  local  and  general  conditions  only  too  familiar  to  us 
in  such  cases.  ISTo  doubt  this  condition  is  amenable  to  ordinary  modes 
of  treatment,  but  to  nothing  does  it  yield  so  thoroughly  and  so  expedi- 
tiously as,  in  my  experience,  it  has  done  to  electrical  treatment. 

The  treatment  may  best  be  begun  by  a  few  applications  of  the 
induced  current.  For  this  purpose  Apostoli's  bipola  intra-uterine 
electrode,  or  the  ordinary  sound-electrode,  and  a  small  abdominal  pad 
may  be  used.  The  coil,  with  somewhat  slow  interruptions,  is  connected, 
and  a  current  as  strong  as  can  be  borne  is  applied  for  ten  or  fifteen 
minutes.  This  may  be  repeated  three  or  four  times  a  week  for  a  fort- 
night or  three  weeks.  The  effect  of  this  seems  to  be  to  increase  the  tone 
of  the  uterine  muscle,  and  materially  to  diminish  the  congestion.  At 
the  end  of  this  time  it  will  be  found  that,  although  the  cavity  is  not 
appreciably  shortened,  the  walls  are  less  flabby,  certainly  less  thick  and 
swollen ;  and  there  is  far  less  tendency  to  backward  flexion.  The  general 
feeling  of  pelvic  distress  is  also  greatly  relieved.  The  application  of  the 
continuous  current  may  now  be  commenced.  Here  again  the  anode  is 
used  internally,  the  full  length  of  the  platinum  electrode  being  employed, 
and  the  treatment  carried  out  in  the  way  indicated  for  endometritis. 
Smaller  currents  up  to  TOO  m.a.  will  suffice.  After  ten  or  twelve  apj^li- 
cations  the  uterus  will  be  found  markedly  diminished  in  length,  the 
white  discharge  almost  gone,  and  the  periods  normal  in  amount  and  dura- 
tion. Fifteen  to  twenty  applications  will  be  sufficient.  If  at  the  end  of 
this  time  there  be  any  tendency  to  displacement,  a  pessary  should  be 
fitted  and  worn  for  a  few  weeks.  The  same  precaution  as  to  the  avoid- 
ance of  a  risk  of  conception  must  Ixi  insisted  on  as  in  the  treatment  of 
endometritis. 

Fibroid  Taraours  of  the  TReru.s. — The  great  interest  which  in  recent 
years  has  been  aroused  in  the  application  of  electricity  to  the  treatment 
of  pelvic  diseases  in  women  is  undoubtedly  due  to  the  work  of  Apostoli 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    325 

of  Paris  ;  it  began  when  the  account  of  his  results  in  the  treatment  of 
fibroid  tumours  was  publislied  in  1886.  His  methods  Avere  a  complete 
departure  from  anything  which  had  been  attempted  previously,  and  the 
results  were  in  themselves  so  striking  that  attention  was  at  once  arrested. 
To  him,  then,  is  due  any  credit  which  is  associated  with  this  form  of  treat- 
ment. No  doubt  a  considerable  number  of  attempts  had  been  made  to 
utilise  this  form  of  energy  for  the  purpose  of  treating  various  forms  of 
gynaecological  diseases  by  previous  workers,  but  the  methods  were  crude 
and  the  results  insignificant.  A  strong  claim  of  precedence  was  made  by 
Cutter,  and  by  others  on  his  behalf,  in  America;  but  it  has  been  shown 
again  and  again  that  the  apparatus  used  by  Cutter  was  quite  incapable  of 
giving  anything  like  an  appreciable  current,  and  that  the  effects  produced 
must  have  been  due  to  other  than  electrical  agency.  Apostoli's  position 
rests  on  the  fact  that  he  employed  strong  currents  which  were  accurately 
measured,  and  which  were  applied  on  a  definite  principle,  depending 
on  the  characteristic  action  of  the  different  poles.  He  certainly  was  the 
first  to  show  how  the  currents  might  be  obtained,  how  they  should  be 
measured,  and  especially  how  they  could  be  brought  to  bear  on  the  tis- 
sues to  be  dealt  with.  Until  he  did  it  no  current  approaching  200  m.a. 
had  ever  been  transmitted  through  the  human  body  for  therapeutic 
purposes ;  he  showed  very  clearly  how  this  could  be  done,  and  he  also 
demonstrated,  to  a  great  extent,  the  result  of  such  an  application. 
Apostoli's  communication  aroused  great  interest  all  over  the  world,  and 
very  speedily  a  number  of  gynaecologists  were  engaged  in  an  extensive 
series  of  clinical  experiments  to  verify  or  disprove  the  results  alleged  by  the 
originator  of  the  treatment.  Many  of  these  experiments  were  of  the  crudest 
kind,  and  in  some  cases  were  attempted  by  men  who  knew  little  or  nothing 
of  the  nature  of  the  energy  they  were  endeavouring  to  use,  and  with 
apparatus  quite  incapable  of  providing  or  applying  that  energy.  Not 
only  so,  but  Apostoli's  statements  were  misread,  and  he  was  credited  Avith 
alleging  results  which  he  never  did  allege.  Because  he  said  that  some 
tumours  diminished  or  disappeared,  it  seemed  to  be  assumed  by  some  of 
his  critics  that  all  tumours  should  disappear  under  this  form  of  treatment ; 
and  as  they  did  not  do  so  his  assertions  were  regarded  as  unfoimded.  It 
is  probable,  too,  that  a  misapprehension  of  the  scope  of  the  treatment 
arose  from  the  unreasonable  claims  which  were  made  for  it  by  some  of  its 
upholders  ;  thus  again  acertain  disappointment  and  sense  of  failure  arose 
in  the  minds  of  those  who  were  endeavouring  to  obtain  results  which  should 
never  have  been  claimed.  For  a  time  the  discussion  was  keen,  not  to  say 
acrimonious ;  and  extreme  opinions  were  freely  expressed.  Time  has 
allayed  the  turmoil  of  the  debate,  and  the  method,  if  practised  by  a 
smaller  number,  is  receiving  a  fairer  trial  and  is  being  placed  on  a 
sounder  basis.  "  Apostoli's  method "  is  now  generally  regarded  by 
those  who  have  given  it  a  fair  and  intelligent  trial  as  fulfilling  a  cer- 
tain well-defined,  but  highly  important  function  in  gyna'-cological  tliera- 
peutics  ;  and  tliose  who  have  not  given  it  such  a  trial  have  no  right  to  an 
opinion  one  way  or  the  other. 


SYSTEM   OF  GYNECOLOGY 


The  symptoms  arising  from  the  presence  of  a  fibroid  ttunour  of  the 
uterus  are  the  f  ollo^ying :  — (i)  Haemorrhage  ;  (ii)  Pain  ;  (iii)  Pressure 
symptoms.  These  may,  however,  be  entirely  absent  in  some  cases  of 
fibroids  even  of  considerable  size.  On  the  other  hand,  they  are  often  all 
present  together  in  one  subject. 

The  cause  of  the  hsemorrhage  is  undoubtedly  the  great  vascularity 
induced  by  the  growth  ;  and  the  blood  seems  to  come  not  only  from  that 
portion  of  the  mucous  membrane  which  lies  on  the  surface  of  the  neoplasm, 
but  from  the  whole  endometrium  as  Avell.  It  may  show  itself  at  the 
menstrual  periods  only,  or  it  may  occur  also  during  the  intermenstrual  time. 
The  pain  may  arise  from  various  causes.  It  may  be  due  to  the  growing 
fibroid  pressing  upon  and  straining  the  uterine  nerves,  to  irregular  uterine 
contractions  set  up  by  the  presence  of  the  tumour,  to  the  production  or 
straining  of  peritoneal  adhesions,  and  to  the  compression  of  nerves  with 
which  it  comes  into  contact. 

The  pressure  symptoms  chiefly  affect  the  bladder  and  rectum,  and 
often  disturb  their  functions  to  a  very  great  extent.  They  may  also  act 
on  the  pelvic  veins,  causing  heemorrhoids  and  varicose  veins  of  the  lower 
limbs.  In  large  tumours  the  effect  of  pressure  may  manifest  itself  on 
organs  so  remote  from  the  pelvis  as  the  stomach  and  heart.  The  most 
acute  form  of  pressure  effect  is  seen  in  the  case  of  growing  fibroids  which 
have  become  incarcerated  in  the  pelvis.  In  these  cases  the  suffering  at 
times  becomes  intense. 

To  the  relief  of  these  symptoms,  pain,  haemorrhage,  and  pressure,  the 
electric  treatment  of  fibroids  is  directed.  If  it  succeeds  in  relieving 
these  it  not  only  removes  the  danger  of  death  (which,  though  com- 
paratively rare  from  a  fibroid  tumour,  yet  may  result  from  sudden  or 
continuous  hsemorrhage,  or  from  gangrene  during  spontaneous  enuclea- 
tion), but  it  also  removes  or  greatly  ameliorates  all  those  consequences 
of  the  presence  of  the  tumour  which  tend  to  interfere  with  the  dis- 
charge of  ordinary  duties,  and  in  many  cases  render  life  a  daily  increasing 
burden.  The  aim  of  the  gynaecologist  is  not  to  remove  the  tumour, 
nor  greatly  to  diminish  its  bulk  ;  it  is  simply  to  abolish  those  conditions 
which  impair  the  activity  of  the  subject  of  it,  render  her  life  a  burden,  or 
even  menace  her  existence. 

It  is  to  this  relief  of  the  symptoms  of  fibroid  tumours  that  those  who 
have  systematically  and  carefully  carried  out  Apostoli's  method  are  pre- 
paredto  lay  claim ;  and  when  we  consider  that,  in  the  great  majority  of  cases 
of  this  exceedingly  common  disorder,  these  symptoms  are  the  only  serious 
ones,  it  must  be  admitted  that  the  claim  is  no  insignificant  one. 

I  repeat  it  is  not  alleged  that  tumours  are  necessarily  dispersed 
or  materially  diminished  in  bulk  by  electrical  treatment,  however  long 
or  energetically  carried  out;  that  both  these  events  happen  from  time 
to  time  is  no  d(rubt  true,  biit  the  symptomatic  cure  which  is  claimed 
as  the  aim  and  result  of  this  treatment  does  not  depend  on  the  disappear- 
ance or  even  on  a  considerable  diminution  of  the  tumour.  To  those  who 
have  had  even  a  moderate  experience  of  this  method,  it  is  known  that  a 


THE   ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    327 

tumour  which  Avas  a  menace  to  life  may  cease  to  give  any  inconvenience 
"without  undergoing  any  appreciable  diminution  in  size. 

The  question,  then,  naturally  arises  how  these  symptomatic  amelio- 
rations are  brought  about  ?  How  are  the  hsemorrliage,  the  dysmenor- 
rhoea,  and  the  general  pelvic  distress  relieved  by  electrical  treatment  ? 
The  answer  to  this  question  is  by  no  means  clear.  That  the  results  are 
such  as  I  have  stated  is  certain ;  the  explanation  of  the  results  is  a 
matter  of  some  doubt.  One  or  two  considerations  may,  however,  help 
to  throw  light  on  this  subject :  first,  as  regards  the  arrest  of  hgemorrhage, 
we  know  that  the  source  of  it  is  the  congested  endometrium ;  we  have 
seen  that  electricity  will  cure  ordinary  haemorrhagic  endometritis,  and  it  is 
not  unlikely  that  if  a  fibroid  be  present  in  the  uterus  the  endometrium  is  in 
a  state  not  unlike  that  found  in  endometritis.  It  is  probable,  then,  that 
the  action  of  the  intra-uterine  pole  is  such  as  to  change  the  state  of  the 
endometrium  and  so  to  diminish  its  tendency  to  bleed.  But  it  is  not 
always  necessary,  in  order  to  produce  this  control  of  haemorrhage,  that  the 
metallic  electrode  should  come  in  contact  with  the  endometrium.  There 
are  some  cases  of  haemorrhagic  fibroid  in  which,  on  account  of  the  displace- 
ment of  the  uterus,  it  is  impossible  to  introduce  a  sound.  In  these  cases 
electro-puncture  of  the  projecting  mass  of  the  fibroid  may  be  resorted  to ; 
and  though,  in  such  a  case,  the  endometrium  is  never  reached,  the 
haemorrhage  comes  very  soon  under  control.  This  clearly  shows  that, 
while  electrolytic  effects  on  the  mucous  membrane  may  be  part  of  the 
explanation  of  electro-haemostasis,  it  is  not  the  whole  explanation. 
Other  and  more  obscure  effects  of  the  electric  application  must  play 
an  important  part  in  the  process.  One  of  these  effects  seems  to  be 
the  distinct,  though  limited  and  probably  temporary,  shrinkage  of 
the  tumour,  which  is  probably  due  to  the  stimulation  of  the  muscular 
tissue  of  the  uterus  and  tumour ;  for  there  seems  no  doubt  that  those 
tumours  which  contain  most  muscular  tissue  are  most  susceptible  to  treat- 
ment. This  shrinkage  can  be  inferred  from  these  two  facts :  firstly,  after 
a  sitting  in  which  the  positive  pole  has  been  used,  bimanual  examination 
will  give  a  distinct  impression  that  the  tumour  has  become  more  firm  and 
condensed  than  before;  and,  secondly,  in  cases  of  tumour  threatening 
impaction,  although  before  a  sitting  it  may  often  be  found  quite  im- 
possible to  raise  the  mass  out  of  the  pelvis,  or  even  to  shift  its  position, 
and  that  the  attempt  to  do  so  causes  intense  pain,  yet  immediately  after 
the  sitting  it  can  be  pushed  well  up  into  the  abdomen,  with  very  little 
inconvenience  to  the  patient.  Such  a  change  can  only  be  explained  by 
a  change  in  the  bulk  of  the  tumour.  It  seems,  tlien,  quite  likely  that  the 
haemostatic  effect  may,  to  some  extent  at  any  rate,  be  a  secondary  result 
of  muscular  contraction. 

It  is  well  recognised,  of  course,  that  the  continuous  current  has  a 
marked  effect  in  producing  powerful  contractions  of  the  uterus.  This  can 
be  demonstrated  experimentally;  and  it  is  shown  clinically  by  the  consid- 
erable number  of  intra-uterine  fibroids  which  have  been  expelled  during 
electrical  treatment,  in  some  cases  after  a  very  few  applications.     It  is 


32S  SYSTEM  OF  GYNECOLOGY 

further  quite  probable  that  we  must  look  to  this  contraction-producing 
effect  for  an  explanation,  not  only  of  the  haemostatic  results,  but  also  of 
the  alteration  of  nutrition  and  consequent  diminution  in  size  which  not 
infrequently  result  from  electrical  treatment. 

The  patholog}^  of  fibroid  tumours  and  their  clinical  classification  have 
been  dealt  with  in  another  part  of  this  work. 

The  indications  for  electrical  treatment  must  now  be  considered,  and 
on  the  other  hand  the  conditions,  whether  in  the  tumour  itself  or  its  sur- 
roundings, which  forbid  its  use.  To  take  the  latter  first,  we  may  enumerate 
the  following  conditions :  —  (a)  Tumours  which  give  rise  to  no  symptoms 
of  haemorrhage  or  pain,  and  which  are  either  small  enough  to  lie  comfort- 
ably in  the  pelvis,  or  are  large  enough  to  occupy  part  of  the  abdominal 
cavity,  are  generally  subserous,  and  in  many  cases  are  connected  to  the 
uterus  by  a  more  or  less  defined  pedicle.  Little  benefit  will  accrue  from 
electrical  treatment  in  these  cases,  however  long  it  may  be  carried  out : 
they  are  best  left  alone,  (h)  Tumours  belonging  to  the  fibro-cystic  type 
are  not  amenable  to  electrical  treatment.  These  often  grow  rapidly,  and 
are  usually  associated  with  a  sero-sanguinolent  discharge,  often  profuse  in 
amount :  it  is  almost  universally  admitted  that  electricity  has  little 
influence  on  them,  and  prolonged  attempts  may  tend  rather  to  increase  the 
amount  and  frequency  of  the  haemorrhage.  Moreover,  the  electrical 
application  seems  to  have  no  influence  in  controlling  the  growth  of  these 
tumours,  probably  owing  to  their  scanty  and  disorganised  muscularity, 
(c)  The  soft,  gelatine-like  fibroid  (the  "  oedematous  "  fibroid  of  Tait)  has 
many  clinical  characters  in  common  with  the  fibro-cystic  variety.  It  seems 
in  all  cases  to  resist  electrical  treatment,  and  is  indeed  apt  to  undergo 
reactions  of  an  unsatisfactory  and  undesirable  kind  on  persistent  attempts 
at  treatment,  (d)  The  presence  of  any  degree  of  purulent  salpingitis 
ought  to  be  regarded  as  an  absolute  contra-indication.  In  the  first  place, 
this  complication  renders  the  tolerance  of  an  effective  current  impossible  ; 
and,  secondly,  it  has  been  found  that  even  small  currents  (20-30  m.a.),  if 
administered  in  such  cases,  are  always  followed  by  an  increase  in  the  local 
pain,  sometimes  by  rigors  and  by  a  rise  of  temperature.  Such  sequelae 
must  Ije  regarded  in  any  case  in  which  they  occur  as  an  absolute  contra- 
indication, ((i)  A  chronic  peritonitis  in  connection  with  a  fibroid,  which 
has  set  up  firm  adhesions  of  the  tumour  either  to  the  parietal  peri- 
toneum or  to  adjacent  viscera,  must  be  approached  with  much  caution. 
It  is  undoubtedly  a  fact  that  some  of  these  cases  of  peritoneal  adhesions 
yield  in  a  remarkable  way  to  the  use  of  electrical  treatment,  and  in  them 
the  procedure  is  more  than  justified.  In  others,  however,  the  same 
reactions  as  those  noted  under  (d)  appear,  and  in  them  further  attempts 
must  be  abandoned.  Accordingly,  in  such  cases  tentative  measures 
with  a  very  weak  current  at  first  may  b(!  tried,  the  results  being  carefully 
noted  and  subsequent  prcKiedure  there])y  regulated. 

Turning  now  to  the  indications  for  the  electrical  treatment  of  uterine 
fibroids,  we  may  make  the  general  statement  that  all  fibroids  —  whether 
submucous,  interstitial,  or  even  subperitoneal — which  give  rise  to  haemor- 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    329 

rhage  or  pain,  which  do  not  belong  to  the  pathological  varieties  above 
noted,  and  which  are  not  complicated  with  suppurative  or  inflammatory 
conditions  in  the  uterine  annexa,  are  fit  for  treatment  by  electricity. 

It  is  almost  unnecessary  to  say  that  no  one  supposes  that  the  symp- 
toms will  be  cured  in  every  such  case ;  but  under  fair  and  reasonable 
conditions  the  pain  and  haemorrhage  will  be  so  completely  relieved  in 
the  great  majority  of  them  as  to  remove  the  burden  from  life,  and  render 
existence  not  only  tolerable,  but  enjoyable. 

Of  the  various  clinical  types  which  yield  to  treatment  one  may  single 
out  as  specially  amenable  submucous  tumours  of  moderate  size,  of  fairly 
soft  consistency,  in  which  growth  is  fairly  rapid,  and  in  which  the  periods 
and  intermenstrual  haemorrhage  are  fairly  profuse.  Under  this  treat- 
ment the  growth  is  distinctly  arrested,  the  heemorrhage  is  reduced  to  that 
of  a  normal  period,  the  pain,  if  it  exists,  is  abolished  or  greatly  relieved, 
and  the  sense  of  well-being  is  enormously  exalted.  And  these  are  just 
the  groups  of  tumours,  occurring  as  they  do  most  frequently  between 
the  ages  of  thirty  and  forty,  which,  by  their  continued  and  recurring 
haemorrhages,  reduce  activity  to  the  lowest  point,  and  vitality  to  the  nar- 
rowest verge  of  existence. 

Method  of  Treatment.  —  "We  may  now  consider  the  special  details  of 
procedure  in  dealing  with  these  cases.  It  cannot  be  too  strongly  kept 
in  mind  that  success  entirely  depends  on  close  attention  to  these  details, 
to  the  general  care  of  the  patient,  and  on  watchfulness  in  regulating  the 
manner,  frequency,  and  vigour  of  the  applications. 

Before  the  sitting  the  patient  should  take  a  copious  douche,  contain- 
ing boric  or  carbolic  acid,  or  some  other  suitable  antiseptic ;  the  temper- 
ature of  which  should  be  between  115°  and  120°  F.  The  high  tempera- 
ture seems  to  check  any  haemorrhage  which  may  be  going  on,  and  also 
acts  usefully  as  a  stimulant.  After  being  placed  on  the  couch  the  first 
step  should  be  the  introduction  of  the  sound.  Apostoli  and  some  others 
recommend  that  the  abdominal  pad  be  placed  in  position  first,  the  object 
of  this  being  to  give  it  time  thoroughly  to  saturate  the  skin  and  to  get 
into  good  contact  with  it  before  the  current  is  turned  on.  My  objection 
to  this,  however,  is  that  it  necessitates  the  introduction  of  the  sound 
while  the  patient  is  on  her  back.  Most  people  in  this  country  are  far 
more  expert  \\\  passing  the  sound  with  the  patient  on  her  side  ;  and  as  it 
is  of  the  first  importance  that  the  sound  be  passed  with  as  little  effort  and 
with  as  little  disturbance  of  parts  as  possilile,  it  is  obviously  better  that 
it  should  be  done  in  that  attitude  in  which  the  greatest  skill  and  dexterity 
are  available.  Moreover,  the  time  occupied  by  adapting  the  pad  is  well 
spent  in  allowing  any  pain  set  up  by  the  introduction  of  the  sound  to 
subside;  so  that  it  may  not  in  any  way  interfere  with  the  tolerance  of 
the  maximum  current.  The  introduction  of  the  sound  is  a  matter  of  vary- 
ing difiiculty  in  these  cases.  Sometimes  it  is  quite  simple,  sometimes  it 
is  a  matter  of  extreme  difficulty,  involving  no  little  dexterity  and  patience. 
A  careful  bimanual  examination  will  often  help  us  much  in  indicating 
the  relations  of  the  uterus  and  tumour,  and  the  j^robable  lie  of  the  uter- 


SYSTEM   OF  GYNAECOLOGY 


ine  canal.  If  any  difficulty  is  anticipated  it  is  often  wisest  to  use  first 
the  ordinary  Simpson  sound,  with  which  one  is  most  familiar,  to  deter- 
mine the  direction  of  the  canal  and  the  presence  of  any  projection  which 
may  cause  difficulty.  When  this  is  withdrawn,  and  the  various  move- 
ments required  to  insert  it  are  carefully  borne  in  mind,  the  electric  sound 
may  often  be  passed  with  ease.  The  most  troublesome  cases  are  those 
in  which  the  cervix  is  tilted  very  high  up,  either  in  front  or  behind,  by 
the  retroversion  or  anteversion  of  the  tumour;  and  of  these  two  the 
former  is  the  more  objectionable.  The  annoying  thing  about  these  cases 
is  that  when  the  tumour  is  moderate  in  size  the  directioa  of  the  canal 
varies  from  time  to  time,  so  that  each  sitting  is  complicated  Avith  the 
trouble  and  time  spent  in  introducing  the  sound.  In  cases  where  the 
uterus  is  lying  forward  the  tendency  to  shift  is  not  so  marked,  and  the  di- 
rection once  determined  makes  it  easy  to  pass  the  electrode  subsequently. 
The  sound  having  been  inserted,  the  patient  turns  on  her  back,  the 
sound  being  held  with  the  finger  in  the  vagina  to  make  sure  that  it  does 
not  shift  in  any  way.  The  close  contact  of  the  abdominal  pad  is  quickly 
assured  by  sponging  the  skin  of  the  abdomen  with  hot  water  previous  to 
its  application;  and  by  the  time  it  is  adjusted  any  pain  set  up  by  the 
introduction  of  the  sound  has  had  time  to  subside.  The  current  is  now 
slowly  turned  on,  with  the  precautions  already  indicated.  At  the  first 
sitting  we  should  be  content  with  a  current  strength  of  60  m.a.,  or  even 
less.  This  is  usually  well  borne,  and  the  patient  gains  confidence  by  dis- 
covering that  any  discomfort  produced  is  moderate  and  easily  supported. 
A  duration  of  five  minutes  after  this  current  strength  has  been  attained 
should  suffice.  The  positive  pole  should  always  be  employed  internally ; 
in  bleeding  fibroids  this  rule  admits  of  no  exception :  the  negative  pole 
causes  more  pain,  and  is  apt  to  be  followed  by  free  haemorrhage.  After 
the  current  is  stopped,  and  the  apparatus  removed,  the  patient  should  lie 
down  on  a  comfortable  couch  for  twenty  or  thirty  minutes  ;  and  on  going 
home  she  should  either  go  to  bed  at  once,  or  keep  to  a  couch  for  the  rest 
of  the  evening.  Before  retiring  for  the  night  another  hot  douche  should 
be  taken.  The  application  should  be  made  twice  a  week,  and  the  current 
gradually  strengthened  until  100  to  150  m.a.  are  reached.  I  am  con- 
vinced that  there  is  nothing  to  be  gained  from  the  use  of  higher  strengths ; 
they  exhaust  the  patient  more,  and  have  no  countervailing  advantage. 
Until  at  least  eight  applications  have  been  made  (that  is,  for  about  the 
first  month)  the  patient  must  be  cautioned  against  any  undue  exertion ; 
indeed  she  should  rest  as  much  as  possible.  Scrupulous  attention  must  be 
paid  to  tlie  action  of  the  bowels,  as  troubles  of  various  kinds  may  follow 
consti[)ation  even  of  a  day's  duration.  The  management  at  the  periods  is 
a  matter  of  y)rime  importance.  It  is  commonly  found,  that,  at  the  first 
period  after  treatment  has  begun — after,  say,  four  or  five  applications  have 
been  given — the  flow  begins  by  a  slight  sero-sanguinolent  discharge,  which 
may  last  for  three  days  or  so  before  the  establishment  of  the  period 
proper.  At  one  time  I  was  in  the  habit  of  ignoring  this  flux  and  making 
the  a[)|)li''a,tion  as  usual.     This,  I  now  think,  is  a  mistake;  for  I  have 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    331 

frequently  found  that  it  was  immediately  followed  by  a  very  profuse 
hsemorrliage,  often  of  a  most  exhausting  and  sometimes  of  an  alarming 
kind.  It  is  better  to  refrain  from  electrical  treatment  under  these 
circumstances,  to  order  a  hot  douche  twice  a  day  until  the  full  dis- 
charge commences ;  and  then  to  advise  the  patient  to  lay  up  for 
three  or  four  days.  At  this  time  —  that  is  three  or  four  days  after  the 
discharge  has  fairly  set  in — the  applications  may  be  resumed,  and  it 
will  generally  be  found  that  the  amount  at  once  diminishes,  and  that 
in  forty-eight  hours  it  has  entirely  ceased. 

At  first  the  long  sound  should  be  used,  exposing  as  much  of  the 
platinum  as  will  lie  in  the  canal.  When  ten  or  twelve  applications  have 
been  made  the  short,  thick  sound  may  be  used,  if  it  can  be  passed,  and 
the  cavity  treated  in  successive  segments.  This  is,  however,  of  less  con- 
sequence in  the  treatment  of  fibroids  than  of  endometritis,  under  Avhich 
head  its  use  has  been  described.  The  number  of  applications  will  vary ; 
in  most  cases  where  the  patient  attends  to  instructions  it  will  be  found 
that  twenty  sittings  Avill  be  enough.  After  the  treatment  is  stopped  the 
first  period  is  usually  somewhat  profuse,  but  the  succeeding  ones  approach 
more  and  more  to  the  normal.  In  others  ten  more  applications  may  be 
required,  but  this  is  exceptional.  In  any  -case  it  is  advisable,  after  giving 
about  twenty  applications,  to  cease  for  a  time  and  to  watch  one  or  two 
periods,  and  then  to  give  a  few  more  if  this  course  seems  to  be  indicated. 
Almost  from  the  very  first  the  improvement  in  general  tone  and  vigour 
is  remarkable ;  the  patient  feels  stronger,  eats  better,  and  especially 
sleeps  sounder.  It  is,  indeed,  in  many  cases,  necessary  to  caution  her 
against  the  too  free  indulgence  in  exercise,  to  which  she  may  be  tempted 
by  her  increased  sense  of  well-being. 

Next  we  may  consider  the  cases  in  which  pain  is  the  special 
symptom.  In  a  certain  number  of  these  the  pain  is  chiefly  dysmenor- 
rhceal,  and  in  them  it  is  usually  accompanied  by  a  considerable  amount 
of  menorrhagia.  The  tumour  in  such  cases  is  either  situated  low  down 
near  the  cervix,  the  uterus  being  usually  markedly  flexed ;  or  the  condition 
is  accompanied  by  a  considerable  amount  of  endometritis,  and  is  char- 
acterised by  the  profusion  of  leucorrhoea  between  the  periods. 

In  such  cases  the  treatment  should  be  conducted  on  much  the  same 
lines  as  in  the  group  already  discussed.  The  pain  at  the  onset  of  the 
period  will  be  very  greatly  relieved  if,  at  the  sitting  just  before  the  period 
is  due,  the  short  sound  be  so  introduced  that  the  active  part  lies  just 
bej^ond  the  os  internum,  and  a  positive  application  be  made  of  the 
maximum  strength  which  can  be  borne.  INIany  cases  seem  to  be  further 
benefited  by  the  use  of  the  induced  current  applied  at  the  same  spot  at 
this  sitting.  Indeed  I  am  in  the  habit  of  using  both  currents  simul- 
taneously during  the  sitting  previous  to  the  period.  This  can  be  done 
most  conveniently  by  the  arrangement  known  as  the  de  Watteville  key, 
which  is  fitted  to  properly  arranged  batteries  and  switch  boards.  The 
strength  of  both  currents  should  be  as  much  as  the  patient  can  bear. 

In  other  cases  the  pain  is  a  more  constant  element;  and  where  it  is 


332  SYSTEM   OF  GYNECOLOGY 

not  due  to  inflammatory  conditions  of  tlie  annexa,  it  is  usually  caused  by 
the  tendency  of  the  tumour  to  become  impacted  in  the  pelvis,  either  as 
the  result  of  its  steady  growth,  or  from  the  vascular  flushing  which 
precedes  the  period  or  sometimes  arises  from  external  causes,  such  as 
constipation.  In  these  cases  examination  will  show  that  the  tumour 
nearly  fills  the  pelvis,  or  else  grows  from  the  wall  of  a  very  much 
retroverted  uterus.  In  either  case  it  resists  any  attempt  at  displacement 
upwards ;  and  such  attempts  are  always  the  cause  of  much  pain.  In 
many  of  the  subjects  of  this  condition  rectal  and  vesical  tenesmus  give 
rise  to  added  distress,  the  latter  especially  being  the  source  of  much 
misery.  It  is  well  known  that  many  of  these  cases  can  be  greatly 
relieved  for  long  periods  by  a  course  of  hot  douches  extending  over  two 
or  more  months.  This  no  doubt  acts  by  stimulating  the  muscular 
fibres,  and  so  diminishing  the  congestion  of  the  organ ;  and  this  some- 
times even  to  such  an  extent  that  the  tumour  may  be  pushed  clear  of 
the  pelvis,  and  prevented  from  returning  to  it  by  means  of  a  ring  or 
other  pessary.  In  most  cases,  however,  it  will  be  found  that  a  quicker, 
and  in  the  end  a  much  more  satisfactory  result  may  be  obtained  by  the 
judicious  use  of  electricity.  It  is  more  speedy,  for  after  two  or  three 
applications  very  violent  tenesmus  may  disappear,  and  it  is  often 
immensely  relieved  after  a  single  application.  But  more  than  this,  the 
influence  of  electricity  is  to  check  the  further  growth  of  the  tumour,  and 
in  many  cases  it  will  actually  produce  a  diminution  of  it ;  to  lift  it 
into  the  abdomen  has  no  such  effect,  but  simply  gives  it  room  to  grow 
without  the  production  of  painful  pressure  symptoms.  Take,  then,  a 
case  in  which  the  tumour  is  nearly  filling  the  pelvis,  and  is  causing  some 
degree  of  vesical  or  rectal  tenesmus.  The  long  sound  should  be  intro- 
duced into  the  uterus,  special  care  being  taken  to  avoid  the  production  of 
all  undue  pain.  If,  in  spite  of  this,  great  pain  is  complained  of  by  the 
time  the  abdominal  pad  is  applied,  the  electrodes  should  be  connected  to 
the  induction  coil,  and  an  induced  current  administered,  of  gradually  in- 
creasing strength,  with  the  interruptions  as  rapid  as  possible,  and  kept 
up  until  a  feeling  of  numbness  is  induced  in  the  pelvis  generally. 
With  the  large  pad  the  current  can  be  borne  nearly  as  strong  as  the 
instrument  can  give,  and  generally  the  numb  sensation  comes  on 
within  ten  minutes.  When  this  is  fairly  established  the  coil  may  be 
disconnected  and  the  continuous  current  applied,  the  sound  being 
positive.  This  should  be  increased  until  GO  to  80  m.a.  are  reached,  and 
the  current  should  tlien  be  maintained  for  about  ten  minutes.  The  same 
care  as  to  rest  and  the  use  of  the  hot  douche  must  be  exacted.  The 
sense  of  relief  which  follows  even  one  application  of  this  nature  is  often 
very  remarkable ;  and  after  five  or  six  sittings  the  patient  will  usually 
express  herself  as  being  quite  comfortable.  It  is  not  wise,  however,  to 
stop  at  this  point.  Fifteen  to  twenty  applications  should  be  given,  and 
it  will  usually  be  found  long  before  this  that  the  uterus  is  freely 
movable,  and  that,  in  the  case  of  a  retrovfu-sion,  a  pessary  can  be  worn 
with  perfect  comfort.     Of  course  in  many  cases  the  passing  of  the  sound 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    333 

gives  rise  to  no  great  pain,  and  in  these  the  preliminary  faradisation  is 
not  necessary.  In  none  need  the  current  ever  exceed  150  m.a. ;  and 
100  m.a.  will  usually  be  found  suf6.cient. 

It  is,  however,  of  the  greatest  consequence  in  connection  with  this 
group  of  cases  to  bear  in  mind  that  some  of  the  symptoms  may  be  due 
to  the  presence  of  conditions  in  the  annexa  —  such  as  pyosalpingitis  — 
which  absolutely  contra-indicate  electrical  treatment.  Where  there  is 
the  slightest  suspicion  of  the  presence  of  such  elements  in  the  case  great 
care  must  be  employed  in  beginning  the  treatment  —  a  small  current 
being  used,  and  any  febrile  reaction  carefully  watched  for.  If  this 
occur,  or  if  the  pain  seem  in  any  way  aggravated  by  the  treatment, 
further  procedure  in  this  direction  should  be  abandoned. 

The  Use  of  Electro-puncture.  —  All  authors  seem  to  be  agreed  that 
wheuever  the  current  can  be  passed  by  the  endometrium,  it  is  better  so 
to  pass  it.  Consequently  whenever  the  sound-electrode  can  be  introduced 
into  the  uterus  without  resort  to  violent  measures,  this  method  of  apply- 
ing the  internal  electrode  should  be  adopted.  There  is,  however,  a  certain 
group  of  cases  in  which  it  is  impossible  to  pass  the  sound.  This  state  of 
things  is  brought  about  by  so  great  a  displacement  of  the  uterus,  back- 
wards or  forwards,  by  the  tumour  as  to  tilt  the  cervix  and  so  put  it  out 
of  reach;  or  it  may  arise  from  the  downward  growth  of  a  lobule  of  a 
large  tumour,  or  of  one  mass  of  a  multiple  tumour,  the  main  body  of 
which  is  in  the  abdomen.  In  these  cases  the  roof  of  the  vagina  is  gener- 
ally occupied  by  a  hard,  solid  mass  of  spherical  outline,  the  cervix  being 
just  within  or  altogether  beyond  reach.  In  such  cases  pain  is  usually 
the  chief  complaint  —  though,  of  course,  haemorrhage  is  often  present  as 
well.  The  passage  of  the  sound  being  out  of  the  question,  the  only 
means  of  dealing  with  the  tumour  electrically  is  by  means  of  electro- 
puncture.  Now,  while  admitting  the  obviously  greater  risk  involved  in 
this  procedure,  I  do  not  for  a  moment  admit  that  the  risk  is  in  any  sense 
sufficient  to  forbid  it,  if  it  be  carried  out  with  certain  simple  precautions. 
The  marvellous  relief  which  may  follow  the  practice  of  puncture  in 
cases  in  which  hysterectomy  is  positively  the  only  alternative,  is,  to  my 
mind,  an  ample  reason  for  its  use  in  properly  selected  cases.  I  have 
used  it  many  times,  and  I  have  had  only  one  case  in  which  its  results 
gave  rise  to  any  anxiety ;  in  that  case  conditions  were  present  which 
can  be  easily  excluded  in  any  other. 

The  instrument  employed  for  the  puncture  has  been  already  described; 
it  is  simply  an  enlarged  electrolysis  needle  (see  Fig.  108) ;  and  the  special 
condition  of  its  introduction  is  that  it  be  buried  at  least  deeply  enough 
to  allow  the  sheathing  to  pass  through  the  mucous  membrane  of  the 
vaginal  roof.  In  this  way  the  formation  of  a  sinus  or  sinuses  in  the  roof 
is  avoided.  On  the  other  hand  if,  as  is  advised  by  Apostoli  and  others, 
a  bare  steel  or  platinum  needle  or  trocar  be  used,  with  the  insulating 
sheath  up  to  the  vaginal  roof,  but  not  through  it,  the  latter  is  acted  upon 
by  the  current  as  well  as  the  deeper  parts,  and  an  open  channel  is  formed 
from  the  vagina  to  the  deepest  part  of  the  puncture. 


334  SYSTEM  OF  GYNECOLOGY 

For  purposes  of  description  let  us  take  a  case  where  the  roof  of  the 
vagina  or  posterior  wall  is  blocked  by  a  fibroid  mass  causing  pain  and 
pressure  symptoms,  and  where  it  is  impossible  to  pass  the  sound.  Im- 
mediately before  the  operation  a  strong  corrosive  or  carbolic  douche, 
copious  enough  to  remove  any  trace  of  discharge  of  any  sort  from  the 
vagina,  must  be  given.  The  patient  should  then  be  placed  on  the  couch 
in  the  dorsal  position.  If  a  bed  be  used  it  must  be  firm,  and  she  must 
lie  as  near  the  edge  of  it  as  possible ;  the  knees  must  be  drawn  up  and 
widely  separated,  and  the  feet  firmly  planted.  As  the  patient  must  not 
be  disturbed  after  the  puncture  is  made,  the  abdominal  pad  should  now 
be  applied  and  its  connecting  cord,  the  positive  one,  attached.  The 
needle,  which  should  have  been  standing  in  a  1-20  carbolic  solution,  is 
now  attached  to  the  negative  connecting  cord  and  taken  in  the  right 
hand.  Its  point,  protected  by  the  pulp  of  the  forefinger,  is  carried  along 
the  vagina  until  the  most  prominent  part  of  the  tumour  is  felt.  The  tip 
of  the  finger  is  used  to  determine  if  any  pulsating  vessel  can  be  felt  over 
this  part ;  if  not,  the  point  is  presented  to  it  and  steadily  held  with  the 
right  hand,  while  the  left  is  employed  to  press  on  the  handle  until  the 
point  passes  \  or  f  of  an  inch  through  the  mucous  membrane.  The 
length  can  be  previously  marked  by  tying  a  piece  of  silk  thread  firmly 
round  the  insulator  at  the  proper  distance  from  the  point.  As  the  needle 
tapers  to  the  point  the  thread,  if  properly  tied,  cannot  slip  up  the  stem, 
and  an  accurate  guide  to  the  depth  of  puncture  is  thus  secured. 

The  pain  caused  is  very  slight ;  it  is  usually  confined  to  that  produced 
by  the  puncture  of  the  vaginal  roof,  and  is  but  momentary.  In  con- 
nection with  this  electro-puncture  a  good  deal  has  been  made  of  the  sup- 
posed risk  of  injuring  the  bladder  or  other  organs  in  introducing  the 
needle.  I  have  never  seen  a  case  where  there  was  the  slightest  risk  of 
such  an  injury.  In  cases  suitable  for  puncture  the  pelvic  roof  is  so  com- 
pletely occupied  by  the  tumour  that  no  other  organ  can  encroach  upon  it, 
and  it  is  quite  safe  to  select  the  most  prominent  part  of  the  tumour  for 
the  puncture.  This  will  usually  be  found  well  behind  the  middle  point  of 
the  pelvis,  Avhere  we  are  a  good  deal  nearer  the  rectum  than  the  bladder. 
Everything  now  being  in  position,  the  needle  is  handed  to  the  nurse,  the 
forefinger  bfiing  kept  in  position  against  the  roof  of  the  vagina  to  make 
sure  that  there  is  no  displacement  as  she  takes  charge  of  it.  The  current 
is  now  carefully  turned  on,  the  same  precautions  being  observed  as  were 
previously  described.  A  strength  of  100  m.a.  is  usually  borne  with  ease, 
and  this  may  be  continued  for  from  five  to  eight  minutes.  As  a  matter 
of  fact  these  negative  electro-punctures  are  rather  more  easily  borne  than 
intra-uterine  aj)plications  ;  and,  after  two  or  three  sittings,  one  may  safely 
use  currents  of  150  to  200  m.a.  When  the  current  is  taken  oif  the 
needle  is  withdrawn,  the  pad  removed,  and  absolute  quiet  enjoined  for 
half  an  hour.  The  patient  may  then  dress  and  go  home,  but  should  go  to 
bed  at  once.  A  douche  must  be  given  at  night,  and  repeated  regularly 
once  a  day  at  least.  There  is  often  a  little  red  discharge  for  a  day  or 
two  after  the  operation,  but  I  have  never  seen  any  serious  haemorrhage 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    335 

follow  it.  It  is  wise  to  allow  a  week  between  each  sitting.  The  same 
precautions  and  procedure  must  be  rigorously  observed  at  the  subsequent 
sittings,  and  it  is  well  to  avoid  puncturing  again  in  the  same  spot  until 
several  weeks  have  intervened.  For  ten  days  or  more  the  site  of  the 
puncture  can  be  recognised  by  the  presence  of  a  little  dimple  or  pucker  ; 
after  that  time  it  should  leave  no  trace. 

Apostoli  and  most  other  authors  enjoin  the  use  of  the  negative  pole 
for  electro-puncture.  This  has  two  advantages  :  1st,  it  permits  the  use 
of  a  steel  needle  for  an  electrode ;  and,  2nd,  the  needle  is  easily  Avithdrawn 
at  the  end  of  the  operation  on  account  of  the  looseness  of  the  disintegrated 
tissue.  It  is  also  supposed  to  have  the  advantage  of  breaking  up  more 
tissue  than  the  positive.  This  difference  is,  however,  rather  apparent 
than  real,  as  we  have  already  seen.  It  has  the  disadvantage  that  it  might 
favour  haemorrhage  through  the  puncture,  if  by  any  chance  there  were  a 
tendency  to  this  accident ;  and  it  has  the  distinct  and  much  more  serious 
disadvantage  of  tending  to  cause  a  congestion  of  the  tissues  in  the  region 
of  the  puncture.  In  this  case  we  should  hardly  expect  the  same  im- 
mediate shrinkage  which  we  certainly  get  in  intra-uterine  positive  applica- 
tions, and  we  should  miss  to  some  extent  the  immediate  and  gratifying 
relief  of  pressure  symptoms  which  usually  follows  a  positive  application. 
There  is  then,  it  seems  to  me,  no  objection  Avhatever  to  the  employment 
of  the  positive  electro-puncture  if  the  negative  fail  to  give  the  desired 
relief.  A  platinum  needle  must  be  used,  and  if,  as  sometimes  happens 
even  with  platinum,  the  needle  does  not  come  away  of  itself  after  stopping 
the  current,  a  negative  current  of  not  more  than  2  or  3  m.a.  for  a  few 
seconds  will  free  it.  We  thus  get  the  soothing  and  congestion-reducing 
eifects  of  the  anode,  with  probably  no  diminution  of  the  electrolytic  in- 
fluence of  the  kathode. 

In  concluding  our  consideration  of  the  treatment  of  fibroid  tumours 
of  the  uterus  by  ''  Apostoli's  method  "  it  will  be  well  to  summarise  the 
claims  made  for  it :  1.  In  submucous  and  interstitial  fibroids  it  controls 
haemorrhage,  abolishes  metrorrhagia,  and  restores  the  period  to  normal 
limits:  2.  It  relieves  pain,  both  menstrual  and  intermenstrual:  3.  It 
produces  an  immediate  diminution  in  the  congestion,  and  hence  in  the 
bulk,  of  an  impacted  tumour;  and,  though  this  may  be  evanescent,  it 
gives  great  relief  to  pressure  symptoms,  and  may  enable  such  a  tumour 
to  be  freed:  4.  The  growth  of  submucous  and  interstitial  tumours  is 
almost  always  completely  arrested :  5.  In  a  certain  number  of  cases  the 
tumour  is  distinctly  reduced  in  size  :  6.  In  a  very  small  number  the 
tumour  may  wholly  or  nearly  disappear:  7.  The  effect  of  the  treatment 
is  a  symptomatic,  not  a  radical  cure. 

Pelvic  Exudations.  — The  frequency  with  which  perimetric  and  ]iara- 
metric  exudations  occur  in  the  female  pelvis,  the  disorganisation  of  func- 
tion they  cause,  and  the  pain  and  distress  they  bring  with  them,  are  well 
known  to  every  gynnecologist.  Xor  is  he  less  well  aware  of  the  persistence 
of  these  deposits,  and  of  their  power  of  resistance  to  almost  every  form 
of  treatment  to  which  they  can  be  subjected. 


336  SYSTEM  OF  GYNECOLOGY 

These  exudations  may  take  the  form  of  a  bulging  mass,  in  one  or 
other  or  both  sides  of  the  uterus,  of  a  dense,  firm,  and  unyielding  quality, 
fixing  the  uterus  and  displacing  it  to  one  or  other  side.  This  form  is 
usually  the  result  of  a  cellulitis  beginning  in  the  cellular  tissue  of  the 
roof  of  the  vagina  on  one  side,  sometimes  being  confined  to  that  side,  but 
often  finding  its  way  to  the  other.  Again,  one  may  find  a  dense  mass 
behind  the  uterus,  occupying  the  pouch  of  Douglas  ;  not  bulging  to  any 
extent  into  the  vagina,  but  binding  the  uterus  to  the  posterior  or  lateral 
aspects  of  the  pelvis.  This  is  most  frequently  the  result  of  a  peritonitis, 
and,  like  the  cellulitis,  is  generally  septic  in  its  origin.  In  other  cases 
the  whole  pelvic  viscera  may  be  matted  together,  the  pelvis  being  roofed 
in,  as  it  were,  by  the  inflammatory  exudation,  partly  perimetric,  partly 
eellulitic.  The  tendency  of  these  deposits  in  the  early  stage  of  their 
history  to  suppuration  is  well  known ;  but  in  many  cases  this  does  not 
occur,  and  the  mass  remains  unchanged  for  months  and  years,  a  constant 
cause  of  pain  and  distress,  of  dysmenorrhcea  and  menorrhagia,  reducing 
the  subject  to  a  state  of  profound  debility  and  misery.  The  treatment 
of  these  deposits  is  often  one  of  the  most  tedious  and  disheartening  ex- 
periences of  gynaecological  practice.  Some  of  them,  no  doubt,  become  ab- 
sorbed, either  spontaneously  or  as  the  result  of  treatment ;  but  in  other 
cases,  the  treatment  by  blisters,  iodine,  ichthyol,  hot  water,  glycerine, 
and  other  remedies,  proves  futile,  and  the  condition  remains  unaltered 
for  an  indefinite  time. 

It  is  in  the  treatment  of  some  of  these  obstinate  and  previously  hope- 
less conditions  that  electricity  has  achieved  some  of  its  most  brilliant 
triumphs.  However  great  may  be  the  difference  of  opinion  as  to  its 
efficiency  in  the  treatment  of  fibroid  tumours,  few  physicians  who  have 
given  its  virtues  a  fair  trial  in  the  present  class  of  cases,  or  have  watched 
the  course  of  a  case  under  treatment,  are  not  compelled  to  admit  that  its 
beneficial  results  are  most  striking.  I  have  seen  an  enormous  exudative 
mass,  which  was  proved  by  an  exploratory  incision  to  have  roofed  in  the 
pelvis  and  filled  every  fold  of  the  peritoneum  with  a  solid  deposit,  dis- 
appear after  twenty -five  applications  of  electricity  ;  indeed  it  required  a 
careful  examination  by  an  expert  to  say  that  there  was  anything  abnormal 
in  the  pelvis.  And  the  patient,  who  had  spent  years  in  bed  as  a  helpless 
invalid,  at  the  end  of  a  few  months'  treatment  was  able  to  take  a  five 
miles'  walk  without  discomfort  or  undue  fatigue. 

The  value  of  this  treatment  in  these  cases  cannot  well  be  overrated. 
Apostoli,  Goelet  of  ISTew  York,  and  others,  are  strongly  in  favour  of 
beginning  the  treatment  of  cases  of  this  kind  during  the  acute  stage, 
when  fever,  pain,  and  the  actual  process  of  exudation  are  going  on. 
They  advise  the  use  of  intra-vaginal  faradisation  with  the  fine  wire  coil, 
asserting  that  this  relieves  the  pain,  calms  the  patient,  and  diminishes 
the  amount  of  exudation.  They  recommend  that  a  bulbous  metallic 
electrode  be  placed  in  the  affected  fornix,  and  gentle  faradisation  carried 
on  until  the  pain  is  relieved,  a  process  which  occupies  fifteen  or  twenty 
minutes,  and  that  this  process  should  be  repeated  once  or  twice  daily. 


THE  ELECTRICAL    TREATMENT   OF  DISEASES   OF   WOMEN    337 

In  the  subacute  stage  the  continuous  current  may  be  substituted,  a  cotton 
or  clay  covered  vaginal  electrode  being  used,  and  a  pad  on  the  abdomen. 
The  current  strength  may  vary  froni  20  to  .30  m.a.,  the  anode  being 
used  internally.  This  again  is  said  to  diminish  the  pain  and  to  reduce 
the  exudation.  These  applications  may  be  made  every  second  day. 
The  only  contra-indication  to  this  line  of  treatment,  according  to  these 
authors,  is  an  intolerance  of  the  application  on  account  of  increase  of 
pain  and  rise  of  temperature.  These  events  are  probably  indications  of 
a  change  in  the  direction  of  suppuration  which  is  generally  regarded  as 
being  an  absolute  contra-indication. 

I  have  had  no  experience  of  this  treatment  at  these  stages  of  the 
disorder,  and  cannot  therefore  speak  of  it  with  any  authority.  But  in 
the  chronic  condition,  when  all  active  change  has  ceased,  and  when  the 
mass  has  assumed  its  firm,  dense,  immovable  character,  I  can  speak  of 
the  value  of  electrical  treatment  with  every  confidence.  When  the  mass 
has  the  general  character  of  a  cellulitis  —  when,  that  is  to  saj^,  it  is  lateral 
to  the  uterus  and  bulges  into  the  lateral  fornix  —  I  believe  the  best  results 
are  to  be  obtained  from  electro-puncture;  and,  following  the  general 
practice,  I  have  always  employed  the  kathode  in  these  cases,  though  here 
again  I  should  suggest  that  this  rule  need  not  be  binding.  The  plan  of 
procedure  is  precisely  the  same  as  in  the  puncture  of  a  fibroid ;  only,  I 
should  advise  that  the  first  few  punctures  be  done  at  the  patient's  house 
so  as  to  give  her  the  benefit  of  complete  rest  after  the  sitting.  The 
current  strength  should  not  exceed  50  in. a.  on  the  first  three  or  four 
occasions,  but  it  may  then  be  gradually  increased  until  100  or  150  m.a. 
are  attained,  provided  no  unfavourable  reaction  follow.  After  a  variable 
number  of  applications,  say  three  to  six,  it  will  be  found  that  the  bulging  is 
steadily  diminishing,  and  that  it  becomes  more  and  more  difficult  to 
define  a  suitable  spot  for  insertion  of  the  needle.  When  this  occurs  the 
subsequent  resolution  is  generally  rapid.  It  seems  undoubtedly  to  be 
favoured,  however,  by  a  systematic  pursuit  of  the  treatment  by  intra- 
uterine application,  and  this  should  now  be  substituted  for  the  piuietures. 
In  a  comparatively  short  space  of  time,  varying  from  two  to  four  months, 
according  to  the  extent  of  the  deposit,  the  treatment  may  be  completed. 
This  will  be  determined  by  the  almost  complete  disappearance  of  the 
mass,  by  the  mobility  of  the  uterus  and  ovaries,  and  by  the  nearly  entire 
cessation  of  pain  and  pelvic  distress. 

In  retro-uterine  perimetric  exudations,  where  a  defined  mass  can  be 
felt,  a  similar  procediire  may  be  resorted  to.  On  account  of  the  greater 
difficulty  of  securing  this  definition,  the  puncture  should  be  made  with 
great  caution,  and  should  never  exceed  half  an  inch  in  depth.  The 
change  in  the  mass  of  adhesions  which  follows  necessitates  an  earlier 
resort  to  intra-uterine  applications  than  in  the  case  of  parametric 
deposits.  On  account  of  the  pain  which  the  negative  pole  always  sets 
up,  these,  at  any  rate,  at  first  should  be  anodal.  In  my  experience, 
perimetric  exudations  are  dispersed  more  slowly  than  parametric  ones ; 
one  explanation  probably  being  that  the  former  can  tolerate  smaller 

z 


338  SYSTEM  OF  GYX.-ECOLOGY 

current  strengths  than  the  latter.  But  the  ultimate  result  in  the 
majority  of  both  cases  is  the  same ;  namely,  an  almost  complete  disper- 
sion of  the  deposit,  restored  mobility  of  the  pelvic  organs,  and  an 
enormous  relief  from  pain. 

R.  Milne  Murray. 

REFERENCES 

A  complete  bibliography  of  gynsecological  electrotherapeutics  will  be  found  in 
Le  Courant  continu  en  Gynecologic,  by  Dr.  Albert  Weil,  Paris,  1895,  embracing 
almost  every  paper  bearing  on  the  subject  from  1857  to  1895. 

The  following  are  some  of  the  more  important  contributions  with  reference  to 
Apostoli's  method :  — 

1.  Apostoli.  "Nouveau  traitement  des  fibromes  de  I'uterus;  lecture  faite  de  29 
juillet  a  I'Academie  des  sciences,"  Comptes  rendus,  1884.  —  2.  Ibid.  "  Sur  nouvean 
traitement  electrique  des  perimetrites,"  Comptes  rendus  Congres  de  Copenhague,  ii. 
141.  —  3.  Ibid.  "Documents  pour  servir  k  I'histoire  de  I'electrotherapie  des  fibromes 
uterins,"  Revue  intern,  d'electrique,  1891. — 4.  Carlet.  Traitement  dlectrique  des 
ribromes  uterins.  These  de  Paris,  1884.  —  5.  Ibid.  "  Traitement  electrique  des  tumeurs 
tibreuses  de  I'ute'rus  d'apres  la  me'thode  du  Dr.  Apostoli,"  Ann.  Soc.  de  med.  de  Gand., 
1885.— 6.  Engelmann,  F.  "Die  Elektricitat  in  der  Gynakologie,"  Arch.  f.  Gyndk. 
xxxvi.  p.  193.  —  7.  GoELET.  The  Electrotherapeutics  of  Gynsecology.  Detroit,  1892. 
—  8.  International  System  of  Electrotherapeutics.  Philadelphia,  1894.  See  various 
articles  by  Grand  and  Famarque,  Goelet,  Kellogg,  etc.  —  9.  Keith,  Thomas.  "Dr. 
.\postoli's  Treatment  of  Uterine  Fibroids,"  Brit.  Med.  Journ.  14th  July  1888.  — 10. 
Keith,  Thomas  and  Skene.  The  Treatment  of  Uterine  Tumours  by  ElectiHcity . 
Edinburgh,  1889. — 11.  Kellogg.  "Summary  of  my  Personal  Experience  with 
Electrolysis  in  the  Treatment  of  Fibroid  Tumours,"  Journ.  Amer.  Med.  Assoc,  vol. 
xviii.  1892.  — 12.  Martin,  Franklin  H.  "Electrolysis  in  Gynrecology,"  Journal 
Amer.  Med.  Ass.  Chicago,  1886,  p.  61.  — 13.  Ibid.  Electricity  in  Diseases  of  Women 
'ind  Obstetrics.  Chicago,  1893.  — 14.  Massey,  Betton.  Electricity  in  Diseases  of 
Women.  Philadelphia,  1889.  — 15.  Munde.  "My  Recent  Experience  with  Electricity 
in  Gynaecology,"  Am.  Journ.  Obstet.  June  1890.  — 16.  Murray,  Milne.  "The  Treat- 
ment of  Pelvic  Disease  by  Electricity,"  Trans.  Edin.  Obstet.  Soc.  1890. — 17.  Nagel. 
"Ueber  die  elektrische  Behandlnng  der  Frauenkrankheiten,  besonders  der  Myome." 
Zeit.  f.  Gebiirts.u.  Gyne.  Bd.  xxii.  Heft  3,  1893.  — 18.  Playfair.  Electricity  in  the 
Treatment  of  Uterine  Disease,  11th  June  1887  and  14th  January  1888.  — 19.  Regnier. 
Traiteinent  des  maladies  des  Fernmes  par  r electricity.  Paris,  1896.  —  20.  Webb.  "On 
the  Treatment  of  Fibroid  Tumours  of  the  Uterus  by  Electricity,"  Brit.  Med.  Jour. 
May  to  July  1887. — 21.  Weil.    Le  Courant  continu  en  Gynecologic.    Paris,  1895. 

E.  M.  M. 


DISORDERS   OF  MENSTRUATION  339 


DISORDERS   OF   MENSTRUATION 

The  line  of  demarcation  between  menstruation  which  conforms  to  the 
normal  order,  and  menstruation  which  presents  features  sufficiently 
abnormal  to  permit  of  its  being  considered  disordered,  is  very  difficult 
to  draw.  Menstruation  which  would  be  normal  in  one  woman,  might  in 
another  be  regarded  as  painful,  or  profuse,  or  scanty ;  even  in  the  same 
subject,  many  deviations  from  the  rule  are  perfectly  consistent  with 
health,  and  are  not  necessarily  due  to  any  local  disease.  In  this 
article  the  various  deviations  from  normal  menstruation  will  be  dis- 
cussed; they  are  but  symptoms,  and  when  due  to  gross  pathological 
lesions  the  description  of  these  must  be  sought  elsewhere.  The  prom- 
inent disorders  are  amenorrhoea,  menorrhagia,  and  dysmenorrhoea,  but 
before  reaching  a  consideration  of  these,  it  will  be  well  to  discuss  the 
(questions  of  premature  and  protracted  menstruation. 

Premature  Menstruation.  —  Menstruation  usually  begins  in  the  fif- 
teenth year,  and  ends  between  forty-five  and  fifty ;  thus  menstrual  life 
normally  lasts  from  thirty  to  thirtj^-five  years.  But  menstruation 
occasionally  sets  in  at  a  much  earlier  age.  One  case  was  recorded  by 
Campbell,  in  which  a  girl  had  menstruated  regularly  every  three  Aveeks 
since  birth.  In  many  of  these  cases  of  precocious  menstruation  the 
general  and  sexual  development  is  premature ;  the  pubis  becomes 
covered  with  hair,  the  mammae  enlarge,  and  both  the  external  and 
internal  generative  organs  undergo  rapid  development. 

I  have  tabulated  the  cases  found  recorded  under  the  following  heads ; 
and,  where  the  case  seemed  one  of  more  outstanding  peculiarity,  I  have 
shortly  epitomised  its  history  :  — 

1.  Precocious  menstruation  with  an  early  appearance  of  the  external 
manifestations  of  puberty. 

2.  Precocious  sexual  development  without  menstruation. 

3.  Menstruation  previous  to  development  of  the  sexual  organs. 

4.  Early  conception  and  pregnancy. 

5.  Premature  sexual  development  associated  with  tumours  of  the 
generative  organs. 

1.  One  of  the  most  striking  cases  illustrative  of  the  first  group  is 
the  oft  quoted  one  of  De  Beau,  to  the  record  of  which  he  considered  it 
advisable  to  append  the  signatures  of  four  physicians,  a  mayor,  and  a 
British  consul. 

The  history  is  as  follows :  — "  Matilda  H.  was  born  on  the  31st 
December  1829.  She  came  into  the  world  with  her  mamnue  perfectly 
formed,  and  the  mons  veneris  covered  with  hairs,  as  much  as  a  girl 
between  thirteen  and  fourteen  years  old.  When  precisely  three  years 
old  the  catamenia  made  their  appearance,  and  have  continued  to  appear 
regularly  every  month  until  the  present  time  (1832),  and  as  copious  as 
any  woman  might  have  them,  each  period  taking  four  days.  .  .  .     Her 


340  SYSTEM   OF  GYNECOLOGY 

mammaB  are  now  of  ttie  size  of  a  full-grown  orange ;  and  the  dimensions 
of  the  pelvis  are,  in  my  opinion,  such  as  to  enable  her  to  bear  children 
when  eight  j'ears  old,  and  very  likely  sooner." 

In  Campbell's  case  (2)  the  catamenia  set  in  a  few  days  after  birth, 
and  occurred  regularly  at  periods  of  three  weeks  and  two  or  three  days. 
This  order  continued  until  the  patient  died  at  the  age  of  four  years. 
Her  appearance  was  that  of  a  girl  of  ten  or  eleven,  the  mammae  and 
external  genitals  having  the  appearances  proper  to  puberty.  The 
development  of  the  pelvis  and  of  all  the  deep-seated  genitals  was  found 
at  the  autopsy  to  be  very  considerable. 

E,.  B.  Smart  gives  a  table  of  eight  recorded  cases,  and  describes  in 
full  detail  a  case  which  came  under  his  own  observation,  with  two 
accompanying  photographs  of  the  patient.  The  catamenia  in  this  girl 
appeared  at  three  years  and  six  months,  and  the  hair  on  the  pubis 
shortly  antecedent  to  that. 

Bouchart  narrates  the  history  of  a  girl,  N.  0.,  and  the  appearance 
she  presented  at  the  age  of  four  years.  She  had  been  born  with  the 
breasts  notably  enlarged,  she  began  to  menstruate  at  the  age  of  twenty- 
two  months,  and  at  the  time  of  examination  she  presented  the  appear- 
ance of  puberty  as  regards  her  breasts  and  genitals.  Menstruation  in 
her  case  was  very  regular  in  its  recurrence,  it  lasted  four  to  six  days, 
and  was  in  quantity  equal  to  that  of  an  adult. 

Harris  classifies  precocious  menstruation  in  two  varieties :  1st, 
that  occurring  during  infancy;  2nd,  that  occurring  between  the  ages 
of  seven  and  thirteen  years.  He  records  the  case  of  a  girl  who  came 
under  his  own  observation,  in  whom  menstruation  appeared  at  the  age 
of  nine  and  a  half  years,  and  in  whom  the  other  evidences  of  puberty 
manifested  themselves. 

C.  E.  Harle  records  the  result  of  a  post-mortem  examination  on  a 
child  who  had  begun  to  menstruate  at  the  age  of  five  months ;  the 
menstruation  returned  regularly  till  the  fourteenth  month,  when  the 
child  died  of  diarrhoea.  The  pudendum  was  large  and  clothed  with  hair ; 
the  uterus  was  large,  the  os  patent  and  the  lips  congested,  the  vessels 
of  the  broad  ligament  were  injected,  and  both  ovaries  were  cystic. 

The  other  cases  I  have  noted  under  this  category  are  the  following :  — 


[Table. 


DISORDERS   OF  MENSTRUATION 


341 


Author. 

Menstruation 

External  Appearances 

began  at  Age  of 

of  Puberty. 

Astley  Cooper  in  Med.  and  Chir.  Trans. 

3  years. 

In  breasts,  axillae  and  on 

1813. 

pubes. 

Thomas  Embling  in  Lancet,  18i8. 

2  years. 

Mammse  and  pubes. 

Aveling  in  Lancet,  186(j,  gives  a  refer- 

ence list  of  sixteen  cases  by  different 

observers. 

Prochownilv  in  Arch.fiir  Gynaek.  1881. 

1  year. 

In  breasts,  axillfE  and  on 
pubes.  Internal  or- 
gans not  enlarged. 

Berry  in  Medical  Pre.ts  for  1882. 

5  years  and  4 
months. 

Breasts  and  genitals. 

A.  van  Denver  in  A7n.  Journal  of  Obstet. 

4  months. 

Mammae  greatly  enlarged. 

1883. 

Fonr  of  the  following  cases  are  cited  by 

Pozzi  in  his  Gynecologic  :  — 

Cabade  in  Gaz.  m'dd.  ch  Paris,  1883. 

8  months. 

Rapid  development. 

Wallent    in    Dissert.    Inaug.    Breslau, 

1       year       3 

188B. 

months. 

Casati  in  II.  Raccoglltore,  1886. 

6  years. 

Rectal  examination, 
"  uterus  pubere." 

Diamant  in   Intern,   klin.    Rundschau, 

6  years. 

Extl.  genitals. 

1888. 

Jagoe  in  Neio  York  Med.  Journ.  1889. 

2  years. 

Extl.  genitals. 

2.  The  indication  of  a  sexual  precocity,  manifested  by  the  outward 
signs  on  the  breasts  and  pudenda,  but  unaccompanied  by  a  menstrual 
discharge,  is  unusual.  Few  instances  of  this  character  have  been  noted, 
but  that  described  by  William  Cook  is  distinctive  enough. 

3.  Menstruation  occurring  without  any  change  in  the  genitals  is  not 
so  unusual  as  the  preceding,  but  it  is  rare  for  a  child  to  have  the 
catamenia  established  for  a  period  of  years  without  other  associated 
phenomena  presenting  themselves. 

Pozzi  cited  Bernard's  case  of  a  girl  who  menstruated  regularh" 
from  birth  up  to  the  age  of  twelve  years  without  any  development  of 
her  genital  organs. 

In  the  same  class  may  be  included  the  cases  noted  by  the  following 
authors :  — 

Allbutt  reports  a  case  where  the  menstrual  discharge  occurred 
periodically  until  the  youthful  patient  died  of  exhaustion. 

Clarence  Harding  reports  that  in  a  family  of  two  daughters  both 
suffered  for  a  time  from  a  periodic  discharge,  hyemorrhagic  in  character, 
in  the  elder  of  whom  the  discharge  vanished  until  puberty  was  estab- 
lished, when  it  recurred. 

4.  Many  reniarkaV)le  instances  of  early  pregnancy  have  been  put 
on  record  by  trustworthy  authorities;  the  majority  of  those  in  this 
country  have  occurred  after  the  age  of  twelve.  There  is,  however,  in 
continental  literature  no  great  scarcity  of  reports  of  pregnancies  at  a 
much  earlier  age. 


342 


SYSTEM  OF  GYNECOLOGY 


The  following  table  of  cases  which  I 
sources  has  been  arranged  in  order  of  age. 
bear  evidence  of  being  trustworthy  :  — 


have  collected  from  various 
The  majority  of  the  records 


Author. 

Reference. 

Develop- 
ment. 

Menstrua- 
tion. 

Impregna- 
tion. 

Delivery. 

State  of 
Child. 

Muller. 

Cyclop,      of 
Obst.    and 
Gxjnec. 

Excessively 
at  birth. 

2nd  year. 

8  years. 

Instrumental, 
S-J  months. 

Dead. 

Schmidt 

Ehmi  is  Histo- 

Se.Yual  organs 

2nd  j'ear. 

8     years    10 

Full      term, 

rigues,  1779. 

developed. 

months. 

dead. 

■  Bodd    . 

1  year  irreg- 
ular,        7 
years  reg- 
ular. 

8    years   10^ 
months. 

Molitor 

Hail-  on  pubis 

4th  year. 

8   years  and 

Premature, 

Foetus  —  a  3 

:u  iia-th. 

3  months. 

5th  month. 

months'. 

Dodd   . 

Lancet,  1881. 

Pul.es      and 
axilla    cov- 
ered    with 
hair. 

12  months. 

8  years   and 
10  months. 

Weighed      7 
lbs. 

j  Rowlett 

Trans.  Med. 
Jour. 

A  few  weeks 
after  birth. 

12  months. 

9   years   and 
3  months. 

10  years. 

73-  lbs. 

Bayliss 

Brit.     Med. 

9  years  and 

10  years  and 

Alive,  weigh- 

and Surg. 

10  months. 

8  months. 

ed  8  lbs. 

Jour.  1846. 

Robertson    . 

Midwifery. 

12th  year. 

12  years  and 
a            few 
months. 

Smith  . 

Lond.  Med. 

Gazette, 
ISiS. 

No  history. 

10  years. 

11  years. 

12^  years. 

Fully  devel- 
oped. 

May     . 

Lancet,  1880. 

Once  before 
conception. 

13  years. 

Well    devel- 
oped. 

Heywood 

Brit.     3Ied. 

12  years  and 

12  years  and 

18  years  and 

Smith 

Jour.  18S1. 

0  months. 

8  months. 

4"inonths. 

Wil.son 

Ed  in.   Med. 
Jour.  1861. 

No  precocity. 

12  years  and 
9  months. 

13  years  and 
(5  "months. 

Full  grown. 

Chapman     . 

Assoc.  Med. 
Jour.  185G. 

13  years  and 
1  month. 

13  3'ears  and 
10  months. 

Full  grown. 

5.  It  has  been  asserted  that  among  the  causes  tending  to  produce 
changes  in  the  sexual  apparatus  peculiar  to  puberty  we  should  include 
neoplasms  affecting  or  related  to  the  internal  generative  organs.  This 
would  appear,  however,  to  be  far  from  the  usual  rule,  and  to  be  rather 
the  exception.  In  order  to  ascertain  the  frequency  of  this  occurrence,  1 
have  examined  the  records  of  twenty-six  laparotomies  performed  on 
children  under  puberty ;  and  in  one  case  only  did  there  seem  to  have 
been  signs  so  marked  as  to  arrest  the  attention  of  the  operator  so 
strongly  as  to  induce  him  to  give  a  description  of  the  child's  appearance. 
On  this  one  occasion  the  narrator  and  operator  was  Mr.  K.  Clement 
Lucas. 

The  child  was  aged  seven,  and  had  had  a  hijemorrhagic  discharge 
from  the  vagina,  which  occurred  whilst  she  remained  in  hospital.  The 
mammae  were  tirm,  and  about  the  size  of  oranges;  the  mons  veneris 
was  of  unusual  elevatitjn,  and  covered  with  hair  about  one  inch  in  length. 
There  was  a  tumour  of  the  right  ovary,  which  was  removed,  and  the 
child  made  a  good  recovery.  The  vaginal  discharge  disappeared,  and 
the  mammary  prominence  subsided  before  she  left  the  hospital. 


DISORDERS    OF  MENSTRUATION  343 

Premature  menstruation  is  in  a  large  measure  hereditary ;  but  a  more 
important  factor  seems  to  be  immoral  associations.  Neglected  children 
by  coming  in  contact  with  vicious  girls  older  than  themselves  frequently 
have  their  attention  prematurely  directed  to  the  sexual  organs.  Bad 
habits,  too,  the  result  of  irritation  produced  by  ascarides  in  the  rectum, 
want  of  cleanliness,  or  caseous  secretions  about  the  clitoris,  may  lead  to  a 
precocious  development.  Over-excitability  of  the  brain  has  also  been 
considered  by  some  authors  as  a  factor  in  the  production  of  a  too  early 
puberty. 

The  management  of  such  cases  consists  in  removing  the  cause  as  far 
as  possible.  Masturbation  should  be  prevented  by  careful  supervision 
of  the  child  and  by  the  relief  of  local  irritations.  General  rest  and 
tonic  treatment  with  removal  from  nervous  excitement  should  be 
advised. 

Protracted  Menstruation. — A  history  of  this  condition  is  to  be  re- 
ceived with  caution.  Women  past  the  menopause  are  apt  to  consider  any 
intermittent  or  irregular  discharge  as  a  continuation  of  the  menses.  Such 
a  hsemorrhagic  discharge  is,  however,  in  most  cases  due  to  the  existence 
of  some  distinct  pathological  lesion ;  such  as  senile  uterine  catarrh,  poly- 
pus, fibroma,  and  especially  cancer :  it  is  sometimes  associated  with  a 
gouty  diathesis.  Nevertheless,  some  authentic  cases  have  been  recorded 
in  which  normal  menstruation  continued  even  till  the  fifty-seventh  year. 
P>ut  it  may  be  taken  as  an  ascertained  fact  that,  so  far  as  normal 
menstruation  with  accompanying  ovulation  is  concerned,  authentic 
cases  of  pregnancy  are  not  recorded  after  the  age  of  fifty-two,  or  of 
fifty-four  at  the  outside.  It  is  safe,  therefore,  to  presume  that  these 
ages  indicate  the  extreme  limit  of  normal  menstruation  accompanied 
by  fertility. 

Amenorrhcea,  or  absence  of  the  menstrual  discharge,  is  primary  when 
the  patient  has  never  menstruated  at  all ;  secondary  when  menstruation 
has  previously  taken  place.  It  exists  as  the  normal  condition  during 
pregnancy  and  lactation. 

Primary  Amenorrhcea.  —  (a)  Primary  permanent  amenorrhcea.  —  The 
most  marked  cases  are  those  in  which  the  ovaries,  or  uterus,  or  both, 
continue  in  a  rudimentary  condition,  or  are  altogether  absent,  while 
the  external  genitals  are  normally  formed.  The  girl's  sexual  develop- 
ment ceases,  and  her  characteristics,  physically  and  mentally,  tend  to 
the  masculine,  or  at  least  to  a  mixed  type.  The  cause  is  absolutely 
unknown.  Heredity,  or  interruption  of  normal  embryonic  development, 
or  interference  with  it,  cannot  be  accepted  as  satisfactory  explanations. 
Nothing  can  be  done  to  relieve  the  condition. 

Cases  of  this  kind  may  be  grouped  in  two  classes :  one  is  charac- 
terised by  complete  absence  of  sexual  development.  The  mammre  are 
undeveloped,  the  pubes  bare  (which  is  specially  characteristic),  and  the 
uterus  and  ovaries  are  found  on  vaginal  examination  to  be  rudimentary, 
if  not  altoarether  absent.     The  second  class  consists  of  cases  of  women 


344  SYSTEM    OF  GYNECOLOGY 

usually  of  "masculine"  habits  —  acrobats,  for  example;  in  them  the 
mammae  are  well  developed,  the  upper  lip  is  hirsute,  there  is  a  copious 
development"  of  hair  over  the  pubes,  and  on  vaginal  examination  the 
uterus  and  ovaries  are  found,  if  not  normal  in  size,  very  nearly  approxi- 
mating to  the  normal.  Such  cases  seem  to  be  accounted  for  by  the  fact 
that  the  muscular  development  of  the  woman  has  been  pressed  from 
early  girlhood  to  such  an  extent  as  to  interfere  with  the  usual  function 
of  the  reproductive  organs. 

(6)  Primary  temporary  amenorrhea  may  be  due  to  chlorosis  occurring 
in  girls  under  the  age  of  puberty.  In  this  condition  the  vascular  system 
is  at  fault ;  not  only  are  the  walls  of  the  vessels  themselves  imperfect, 
but  the  blood  contains  rather  fewer  red  corpuscles  than  is  normal,  and 
they  are  especially  deficient  in  haemoglobin.  In  such  cases,  however, 
there  is  a  tendency  to  plumpness  from  undue  development  of  adipose 
and  cellular  tissue.  The  general  appearances  and  symptoms  of  such 
patients  are  well  known.  Menstruation  occurs  later  than  normal,  and 
when  it  does  set  in  the  flow  is  scanty  and  of  short  duration ;  the  inter- 
menstrual periods  also  are  longer. 

The  treatment  is  the  ordinary  treatment  of  chlorosis  :  it  consists  in 
the  administration  of  arsenic  and  iron ;  rest  at  first  and  exercise  later ; 
careful  non-fattening  diet  and  saline  purgatives.  In  many  cases  the 
digestion  is  also  at  fault,  and  has  to  be  rectified  by  the  usual 
stomachic  remedies.  If  circumstances  permit,  much  advantage  may 
be  derived  from  a  course  of  the  waters  at  such  places  as  Tarasp  and 
Schwalbach. 

(c)  Delayed  puberty.  —  Here  the  general  and  sexual  development  are 
complete,  and  yet  the  girl  fails  to  menstruate.  These  cases  are  some- 
times accounted  for  by  the  fact  that  the  "nutritive  forces  have  been 
directed  towards  the  general  organisation."  Some  such  girls  have  often 
too  much  yjliysical  labour.  Thus  among  the  poor,  who  do  a  great  deal 
of  manual  outdoor  work  at  an  early  age,  menstruation  is  often  delayed. 
On  the  other  hand,  brain  workers  often  exhibit  the  same  symptom ;  by 
overwork  of  the  higher  functions  the  nutritive  and  reproductive  systems 
are  thrown  out  of  balance. 

The  management  of  such  cases  is  easy  and  attended  as  a  rule  by 
satisfactory  results.  Change  of  occupation,  rest  for  the  body  if  the 
physical  strength  has  been  overtaxed,  and  rest  for  the  mind  when  its 
faculties  have  been  strained,  will  generally  effect  a  cure. 

Secondary  Amenorrhoea.  —  This  may  be  the  result  of  various  patho- 
logical conditions.  Thus  it  may  be  due  to  such  constitutional  derange- 
ment as  results  from  anjjcmia,  chlorosis,  diabetes,  ]>right'sdisease,  malaria, 
cancerous  cachexia,  tuberculosis,  acute  illnesses,  and  fever.  In  the  same 
way  acute  or  chronic  surgical  affections  may  be  potent  in  producing 
amenori'hfjia.  Some  authors  lay  much  stress  upcm  the  amenorrhoea 
which  is  the  occasional  result  of  syphilis.  This  symptom,  however,  is 
no  doubt  due  simply  to  the  anaemic  condition  which  is  associated  with 
the  disease. 


DISORDERS   OF  MENSTRUATION  345 

The  suppression  of  the  menses  that  occurs  in  young  obese  women  is 
to  be  accounted  for  in  the  same  way. 

The  influence  of  the  nervous  system  is  distinctly  a  factor  in  the  pro- 
duction of  amenorrhoea.  Thus  a  sudden  fright  has  not  infrequently  been 
known  to  cause  a  temporary  suppression  of  the  menstrual  flow  —  as  when 
an  unmarried  woman  supposes  herself  to  be  pregnant;  on  the  other  hand, 
it  must  not  be  forgotten  that  in  a  few  cases  a  stimulating  rather  than  an 
inhibitory  action  has  been  known  to  follow  a  sudden  emotion,  and  men- 
struation has  set  in.  Again,  amenorrhoea  due  to  the  influence  of  the 
nervous  system  is  shown  in  the  insane,  and  in  prisoners,  a  change  which 
is  due  no  doubt  to  the  mental  depression  consequent  upon  seclusion. 
Chills  are  very  commonly  responsible  for  the  cessation  of  the  menstrual 
flow,  and  in  such  cases  the  influence  may  be  conducted  through  the 
vasomotor  tract. 

The  amenorrhoea  of  pseudo-pregnancy  occurring  in  the  ncAvly  married, 
in  those  Avho  have  been  leading  irregular  lives,  and  in  those  who  are 
reaching  the  menopause,  is  well  known,  and  is  to  be  accounted  for  by 
an  influence  acting  through  the  nervous  system.  Pozzi  defines  it  by 
attributing  it  to  "  auto-suggestion." 

Amenorrhoea  often  occurs  in  young  girls  who  are  sent  to  German^' 
or  France  to  school;  when  the  change  of  climate  and  diet  appears  to 
lead  to  this  symptom.  Similarly,  a  long  sea-voyage  may  produce  such 
a  condition. 

The  local  diseases  which  cause  suppression  are  many.  Atrophy  of 
the  uterus  commonly  leads  to  it,  and  this  may  be  the  result  of  super- 
involution  from  repeated  pregnancies,  prolonged  lactation,  or  tuberculosis. 
So,  too,  many  cases  are  recorded  in  which  an  early  menopause  has  occurred 
without  apparent  reason :  menstruation  gradually  or  suddenly  ceases, 
and  on  examination  the  internal  generative  organs  are  found  in  the 
atrophic  state  of  a  normal  climacteric. 

Tumour  of  the  ovary  may  not  interfere  with  menstruation  in  any 
way ;  but  occasionally,  when  both  ovaries  are  completely  destroyed  by 
cystic  or  other  degeneration,  menstruation  ceases.  If  but  one  ovary  be 
affected  menstruation  may  go  on  fairly  regularly,  as  it  may  when  the 
ovaries  are  the  seat  of  inflammatory  changes.  In  the  early  stage  of 
inflammation  the  tendency  is  rather  to  menorrhagia ;  b^it  in  the  later 
sclerotic  stage  amenorrhoea  does  occasionally  though  rarely  occur. 

Amenorrhoea  due  to  atresia  of  the  cervix  or  vagina  or  hymen  is  a 
condition  which  demands  special  attention.  This  is  not  the  place  in  which 
to  discuss  the  deformities  producing  hajmatometra  and  hsematokolpos,  in 
each  of  which  menstruation  is  prevented  by  the  occlusion  of  the  genital 
canal.  In  most  cases  the  condition  can  be  distinguished  perfectly  Avell 
from  auuMiorrhoea  due  to  non-development  or  to  constitutional  causes; 
whereas  in  the  latter  there  are  none  of  the  local  or  constitutional  dis- 
turbances which  accompany  menstruation,  in  the  former  pain  and  dis- 
comfort are  manifested  with  regularity  every  month,  and  a  well-marked 
bulging  may  be  discovered  at  the  vulva ;  or  a  tumour  may  present  itself 


346  SYSTEM  OF  GYNECOLOGY 

suprapubically.  This  tumour  may  sometimes  be  so  high  as  to  be  mis- 
taken for  one  of  the  abdominal  organs ;  this  was  notably  the  case  in  a 
young  girl  under  my  own  care,  where  a  round  tiimour  presented  itself 
well  up  in  the  ilio-lumbar  region  which  was  mistaken  for  an  enlarged 
kidney.  The  misleading  point  was  that  the  girl  had  constant  pain  in 
this  region.  As,  though  eighteen  years  old,  she  had  never  menstruated, 
an  examination  was  made  of  her  vulva,  and  the  tense,  bulging,  imper- 
forate hymen  was  discovered.  This  was  treated  in  the  usual  way  with 
a  thermo-cautery  ;  slow  removal  of  the  contained  fluid  was  accomplished 
with  complete  antiseptic  precautions,  the  whole  ilio-lumbar  swelling 
disappeared,  and  regular  menstruation  was  established. 

Be  moved  of  the  Ovaries.  —  Whether  removal  of  both  ovaries  causes 
cessation  of  menstruation  or  not,  there  are  two  classes  of  cases  to  be 
considered :  firstly,  those  in  which  an  excised  ovary  was  the  seat  of 
tumours,  cystic,  papillary,  or  solid;  and,  secondly,  those  in  which  the 
ovaries  on  removal  were  either  healthy,  or  were  removed  on  account  of 
some  inflammatory  or  slightly  cystic  condition,  or  on  account  of  dys- 
menorrhoea.  As  regards  the  first  class,  it  is  often  difficult  to  state  for 
certain  that  the  whole  of  the  ovary  has  been  removed ;  a  small  portion 
may  be  left  in  the  pedicle,  and  this  may  be  quite  sufficient  to  account 
for  the  continuance  of  menstruation.  As  regards  the  second  class,  it 
has  been  affirmed  by  Lusk  that  in  the  great  majority  of  cases  (86  per 
cent)  menstruation  ceases,  if  not  at  once,  at  least  within  a  year  of  the 
removal  of  the  ovaries.  In  these  cases  some  authors  have  supposed  the 
existence  of  a  supplementary  ovary ;  but  surely  the  "  law  of  persistence 
of  habit "  is  siifficient  to  account  for  the  phenomenon.  It  is  an  auto- 
matic ebb  and  flow  produced  through  the  influence  of  the  nervous 
system. 

Another  factor  in  the  production  of  this  continuation  of  menstrua- 
tion after  oophorectomy  is  the  condition  of  the  uterine  mucosa.  This  is 
frequently  in  a  congested,  if  not  in  an  inflammatory  condition,  and  for 
this  reason  some  operators  advise  that,  in  all  cases,  curettage  of  the  uterus 
should  be  performed  after  the  removal  of  the  appendages.  Czempin 
considers  it  possible  that  the  cicatrisation  following  the  operation  may 
compress  the  veins,  and  so  keep  up  a  passive  congestion  and  a  continuance 
of  the  monthly  flow.  Oophorectomy  not  only  leads  to  local  disturbances,  — 
chiefly  to  amenorrlujea,  —  but  it  is  apt  to  lead  to  general  physical  changes. 
There  is  an  increase  of  ])lampness  of  the  person,  although  the  mammae 
generally  atrophy ;  and  there  is  frequently  a  change  of  disposition,  which 
often  becomes  more  placid. 

If  the  Fallopian  tubes  alone  are  removed,  the  ovaries  being  healthy, 
these  local  and  general  changes  do  not  occur. 

My  own  experience  in  cases  of  removal  of  the  ovaries  for  inflammatory 
conditions,  tubal  enlai'g(!ments,  and  minor  ovarian  disorders,  does  not 
coincide  with  that  of  Lusk  ;  I  have  found  that  a  much  larger  ])roportion 
of  women  continue  to  menstruate  regularly  for  years  after  the  ovaries  have 
been  removed,  and  that  the  only  difference  in  these  patients  is  that  the 


DISORDERS   OF  MENSTRUATION  347 

irienopause  is  antedated  by  some  years,  and  that,  in  most  of  them,  thougli 
by  no  means  in  all,  menstruation,  if  it  continue,  is  without  pain. 

In  a  few  cases  of  this  kind,  especially  those  in  which  the  operation 
was  undertaken  for  the  cure  of  fibroids,  I  have  found  that  the  haemor- 
rhage has  sometimes  been  increased. 

Though  it  is  obviously  impossible  to  follow  every  case  to  a  definite 
issue,  the  following  is  my  experience  in  the  matter :  — 

Removal  of  the  Ovaries  and  Tubes  for  Minor  Affections. 

100  Cases.     In  40  menstruation  ceased. 

In  30  ,,  continued  irregularly  for  years. 

In  20  ,,  ,,         regularly. 

In  10  ,,  recurred  at  long  intervals. 

Symptoms  of  Amenorrlicea.  —  Besides  the  absence  of  the  periodic  flow, 
which  is,  of  course,  the  chief  symptom,  numerous  constitutional  symptoms 
are  observed  as  the  accompaniments  of  amenorrhcea.  Thus  hysteria  is 
frequently  an  important  and  serious  complication ;  while  minor  sensory 
disturbances,  such  as  amblyopia  and  tinnitus,  may  be  reflex  or  the  resalt 
of  aneemia.  Paresis  has  also  been  known  to  occur,  due  no  doubt  to  the 
accompanying  hysterical  condition. 

There  is  no  question  that  many  forms  of  skin  eruption,  such  as  acne, 
pemphigus,  erysipelas,  herpes,  eczema,  and  urticaria,  may  accompany 
the  suppression  of  menstruation.  Hyperidrosis,  too,  has  been  known 
to  follow  a  sudden  cessation  of  the  monthly  flow. 

Vicarious  Menstruation.  —  Many  cases  are  recorded  in  which  the 
function  of  menstruation  has  been  taken  up  by  other  organs  of  the  body, 
the  condition  being  known  as  vicarious  menstruation.  Jones  reports  a 
most  remarkable  case  in  which,  when  menstruation  was  suddenly  sup- 
pressed by  a  chill,  the  woman  for  five  months  thereafter  had  amenorrhcea, 
but  regularly  in  each  of  these  months  she  had  for  thirty  six  hours  an 
abundant  flow  of  milk  from  the  breasts.  In  another  case  the  catamenia 
were  replaced  by  a  profuse  diarrhoea  which  lasted  for  three  days  every 
mouth ;  and  in  yet  another  a  periodic  leucorrhoea  was  the  only  indica- 
tion of  the  menstrual  function. 

Besides  these  extraordinary  cases,  many  are  recorded  of  haemorrhages 
from  the  respiratory  or  alimentary  tracts,  of  epistaxis,  ha^nnoptysis,  or 
haimatemesis  replacing  the  normal  uterine  discharge.  INIore  rarely 
bleeding  from  the  ear  has  occurred,  and  in  one  or  two  cases  subcutaneous 
haemorrhages  have  been  observed,  or  a  bleeding  from  a  raw  surface,  such 
as  an  ulcer,  has  taken  place  regularly  every  month. 

Perhaps  a  cerebral  apoplexy,  which  occasionally  has  been  known  to 
follow  the  sudden  cessation  of  menstruation  at  the  menopause,  or  the 
cure  of  a  long-continued  ha^morrhoidal  discharge  is  to  be  regarded  as  an 
event  of  a  like  kind. 

Treatment  of  Amenorrhcea.  —  This  naturally  varies  very  much  accord- 
ing to  the  cause.     In  niany  cases  it  is  quite  useless  to  administer  drugs 


348  SYSTEM  OF  GYNECOLOGY 

that  are  supposed  to  act  directly  upon  the  function  of  menstruation, 
without  first  carefully  considering  whether  some  general  constitutional 
condition  may  not  account  for  the  suppression.  No  doubt,  in  some 
cases,  such  drugs  as  rue,  savin,  or  saffron,  have  succeeded  in  restoring 
the  function ;  but  this  result  has  occurred  in  cases  in  which  the  amen- 
orrhoea  was  simply  due  to  a  chill  or  violent  emotion.  When  it  is  the 
result  of  anaemia,  chlorosis,  syphilis,  or  tuberculosis,  these  diseases  rather 
call  for  treatment,  and  the  pelvic  organs  require  no  special  attention. 
In  amenorrhoea  from  chlorosis  —  so  common  in  young  girls  —  treatment 
by  iron  and  arsenic,  baths  and  saline  purgatives,  is  followed  by  excellent 
results ;  but  perhaps  the  most  useful  way  of  combating  these  cases  is 
by  the  persistent  use  of  arsenic,  followed  by  a  short  course  of  aloes  and 
iron  in  pills.  Many  other  remedies  are  attended  with  equally  good 
results.  Manganese  is  considered  by  some  physicians  to  be  as  useful  as 
iron  in  the  treatment  of  anaemia;  it  is  also  supposed  to  have  a  special 
emmenagogue  action :  I  have  not  found  it  nearly  so  satisfactory  as  some 
forms  of  iron.  Judicious  physical  exercise  and  change  of  air  are  also 
important  in  the  treatment  of  amenorrhoea. 

As  regards  local  treatment,  this  in  many  cases  is  of  no  avail.  When 
the  organs  have  become  atrophied  from  any  cause  no  local  treatment 
seems  to  have  much  effect  in  ameliorating  the  condition.  Electricity 
has  been  advocated  by  many  physicians,  and  in  the  hands  of  some  I 
have  no  doubt  it  has  been  occasionally  successful ;  but  my  own  experi- 
ence of  it  has  not  been  very  encouraging. 

In  those  instances  in  which  the  suppression  of  menses  is  due  to  the 
patient's  rapidly  growing  obesity  the  indication  is  clear ;  and  careful 
dieting,  with  baths  and  exercise,  will  generally  effect  a  cure.  Stimula- 
tion of  the  uterine  mucosa  by  gentle  curettage  may  sometimes  be  use- 
ful in  securing  a  return  of  the  menstrual  flow. 

In  the  amenorrhoea  which  results  from  a  premature  menopause  due 
to  the  removal  of  the  ovaries,  the  ordinary  symptoms  of  the  climacteric 
period —  lumbar  pains,  flushings,  giddiness,  and  irritability  —  usually  ap- 
pear. In  such  cases,  besides  the  general  treatment  by  bromides  and  tonics, 
the  patient  occasionally  derives  benefit  from  scarification  of  the  cervix 
every  month  so  as  to  obtain  a  slight  local  bleeding  and  relief  of  congestion. 

The  intrti-uterine  zinc  and  copper  stem  pessaries,  so  much  advocated 
long  ago  by  8ir  James  Simpson,  are,  I  think,  devoid  of  any  important 
galvanic  action,  yet  they  evidently  do  good  in  some  cases,  as  does  scari- 
fication of  the  cervix,  by  permitting  a  temporary  flow  and  giving  a 
temporary  relief. 

Scanty  Menstruation. — This  condition  is  due  to  causes  very  similar 
to  lliosc.  (jf  iiinc.iiorrhdia.  It  may  l)e  eitlier  j)rimary  or  acquired.  If 
])riiiiury  it  remains  constitutiouid  tlirough  ]if(;;  if  acquired  it  is  as  the 
result  of  some  intercurrent  jjatliological  condition,  such  as  those  referred 
to  in  the  description  of  amenorrhea  proper. 

Here,  however,  it  must  not  be  forgotten  that  scanty  menstruation, 
like  menorrhagia,  is  merely  a  relative  term ;  menstruation  is  abnormal 


DISORDERS    OF  MENSTRUATION  349 

when  it  extends  beyond  six  days  in  the  one  direction,  or  is  reduced 
to  two  in  the  other.  It  must  also  be  borne  in  mind  that,  before  any 
opinion  can  be  given,  the  menstrual  habit  of  the  individual  must  be 
accurately  determined. 

The  treatment  is  to  be  on  lines  similar  to  those  laid  down  under  the 
liead  of  amenorrhoea. 

In  a  certain  class  of  cases  inflammation  which,  in  the  first  stage, 
tends  to  cause  menorrhagia,  at  a  later  stage  induces  amenorrhoea.  Such 
eases  are  best  illustrated  by  endometritis.  As  is  well  known,  the 
symptom  of  acute  and  subacute  endometritis  is  menorrhagia;  but 
when  the  condition  has  become  extremely  chronic,  when  the  mucous 
membrane  has  become  thin,  the  vessels  shrunk,  and  the  fibrous  tissue 
greatly  increased,  scanty  menstruation  is  a  well-marked  symptom.  This 
condition  has  also  been  frequently  observed  in  what  is  known  as  parar 
metritis  atrophicans,  in  which,  owing  to  the  contraction  of  an  inflamma- 
tory deposit  in  the  broad  ligament,  the  arterial  supply  to  the  uterus 
has  been  so  curtailed  that  scanty  menstruation  or  even  amenorrhoea  has 
been  the  natural  result. 

Menorrhagia  and  Metrorrhagia.  —  By  the  term  menorrhagia  is  meant 
an  excess  of  discharge  occurring  at  the  time  of  the  usual  menstrual 
period ;  by  metrorrhagia,  haemorrhage  from  the  uterus  not  coincident 
Avith  a  menstrual  epoch.  In  considering  these  two  symptoms  it  is 
necessary,  in  the  first  place,  to  deal  with  the  difficulty  of  deciding  what 
amount  of  haemorrhage  at  the  monthly  period  is  to  be  considered  as  ex- 
cessive ;  and  in  the  second  place,  as  all  bleeding  from  the  vulva,  apart 
from  the  menstrual  flow,  might  at  first  be  considered  as  metrorrhagia,  the 
causes  of  bleedings  which  might  wrongly  be  confused  Avith  metrorrhagia 
must  be  enumerated,  in  order  that  we  may  eliminate  them,  and  find 
ourselves  free  to  deal  with  the  subject  S3^stematically. 

Menorrhagia  may  occur  as  an  excessive  flow  of  blood  during  the 
normal  number  of  days  which  constitute  a  period,  or  as  an  ordinary  flow 
extending  over  an  excessive  number  of  days.  Our  only  means  of 
comparison  is  to  ascertain  if  the  function  differs  from  the  patient's  usual 
habit,  and,  moreover,  if  it  is  affecting  her  general  health. 

In  the  case  of  delicate  anaemic  girls,  ill  enough  able  to  sustain  the 
nutrition  of  their  OAvn  bodies,  even  an  entire  absence  of  menstrual  dis- 
charge is  not  necessarily  to  be  looked  upon  as  an  evil ;  we  may  find  that 
on  the  restoration  of  health  by  tonic  and  restorative  treatment  the 
periodic  discharge  of  blood  will  take  place  without  reducing  the  bodily 
powers :  on  the  other  hand,  there  are  women  who  normally  menstruate 
for  eight  or  ten  days  at  each  period  without  suffering  any  inconvenience 
or  derangement  of  the  general  health.  Thus,  in  a  woman  who  h'as 
menstruated  before,  it  is  only  by  a  consideration  of  her  menstrual  habit, 
and  by  making  due  allowance  for  climatic  and  other  influences,  that  we 
can  determine  the  standard  by  which  her  menstruation  is  to  be  judged. 

At  the  same  time  it  is  well,  for  general  purposes,  to  have  an  arbitrary 


SYSTEM  OF  GYNECOLOGY 


limit;  and  this  we  can  roughly  assign  by  observing  the  average  time 
occupied  by  the  period  in  a  considerable  number  of  women  —  a  matter 
already  discussed  imder  amenorrhoea :  we  should  thus  be  led  to  consider 
the  function  to  be  excessive  if  it  lasted  longer  than  six  days ;  and  the 
actual  amount  of  blood  lost  may  be  estimated  in  terms  of  the  diapers 
employed  —  ten  to  fifteen  being  looked  upon  as  a  fair  average  number 
for  each  period. 

The  term  metrorrhagia  is  held  to  imply  only  bleedings  from  the 
uterus  and  cervix  uteri :  on  the  one  hand,  it  is  obviously  impossible  in  a 
gynaecological  treatise  to  consider  at  length  haemorrhages  occurring  in 
connection  with  pregnancy;  and,  on  the  other  hand,  the  discussion  of 
bleedings  from  the  vagina  and  vulva  belong  to  other  chapters.  It  is  only 
necessary  in  this  place,  in  order  to  facilitate  reference,  that  these  various 
sources  of  haemorrhage  should  be  mentioned. 

Bleeding  associated  with  abortion,  myxomatous  degeneration  of  the 
chorion,  placenta  praevia,  separation  of  the  placenta  ("Accidental 
Haemorrhage  "),  retained  placenta  or  membranes,  inertia  of  the  uterus, 
and  inversion  of  the  uterus,  is  fully  described  in  works  on  Obstetrics. 

Of  sources  of  haemorrhage  which  may  be  mistaken  for  menorrhagia 
we  may  simply  mention  vaginitis,  with  ulcerations  or  other  lesions  of 
the  vagina;  injuries  of  the  hymen  and  vulva;  and  the  rare  occurrence 
of  rupture  of  varicose  veins  in  the  pudenda,  associated  especially  with 
pregnancy. 

We  have  next  to  consider  a  class  of  causes  which  are  independent  of 
the  special  function  of  the  uterus,  but  may  produce  bleeding  from  it  as 
from  any  other  mucous  membrane  of  the  body.  These  causes  depend  for 
the  most  yjart  on  alteration  in  the  condition  of  the  blood.  For  example, 
a  woman  of  the  haemorrhagic  diathesis  will  bleed  much  more  profusely  at 
her  menstrual  epoch  than  other  women,  as  would  be  the  case  with  her  in 
epistaxis,  or  on  the  breach  of  any  other  surface.  Besides  haemophilia, 
scorbutus  and  purpura  act  in  this  way ;  and  although  chlorosis,  as  we 
have  found  above,  tends  rather  to  produce  a  condition  of  amenorrhoea 
with  leucorrhoea,  yet  in  some  cases  it  leads  to  menorrhagia  and  metror- 
rhagia. It  may  be  that  in  these  cases  the  condition  of  the  blood  and  the 
state  of  the  vessels  is  sufficient  to  account  for  the  hijemorrhage  ;  but  some 
local  condition  is  often  found  along  with  these,  such  as  a  small  fibroid 
tumour,  or  a  congested  condition  of  the  uterine  mucosa  due  to  displace- 
ments, which  as  well  as  the  general  condition  require  treatment.  These 
cases  are  amongst  the  most  difficult  to  treat,  because  they  interact  in  such 
a  way  as  to  produce  a  "  vicious  pathological  circle  "  —  the  drain  on  the 
system  l>y  the  haemorrhage  tending  to  aggravate  the  very  systemic  con- 
dition which  in  its  turn  leads  to  the  menori'hagia. 

jMuny  other  g(!n(!ral  (ionditions  (lisj)ose  to  menorrliagia  and  metror- 
rhagia. Of  these  are  long-continued  mental  depression,  hysteria,  and  other 
nervous  disturbances ;  deranged  states  of  the  system  due  to  too  luxurious 
and  too  sedentary  habits  of  life ;  residence  in  tropical  climates,  or  in 
damp,  unhealthy  situations ;  malaria ;  tubercle ;  the  acute  exanthems 


DISORDERS   OF  MENSTRUATION  351 

("  uterine  epistaxis  "  associated  with  typhoid  fever) ;  lead  and  phosphonis 
poisoning,  and  Bright's  disease. 

Haemorrhage,  again,  may  be  associated  with  disorders  of  the  circulati  on . 
Backward  pressure,  especially  as  the  result  of  mitral  incompetence  or 
stenosis,  or  a  congested  condition  of  the  vessels  of  the  pelvis,  the  result  of 
pressure  exerted  on  the  veins  of  the  portal  system  by  new  growths,  is 
apt  to  produce  bleeding,  which  like  the  epistaxis  that  sometimes  appears 
to  save  a  patient  from  a  cerebral  haemorrhage,  may  be  looked  upon 
as  a  relief  of  congestion.  In  most  cases  of  the  kind,  however,  we  may 
suspect  the  presence  of  a  predisposing  local  condition  in  a  diseased 
state  of  the  uterine  mucous  membrane. 

Cirrhosis  of  the  liver  and  kidneys  is  a  cause  belonging  to  the  same 
class ;  and  when  the  cirrhosis  itself  is  due  to  alcoholism  we  may  find  a 
threefold  cause  in  hepatic  cirrhosis,  in  a  hypertrophied  and  dilated 
state  of  the  heart,  and  in  a  diminished  activity  of  inhibitory  nervous 
centres  or  tracts. 

Such  are  the  chief  general  conditions  Avhich  may  dispose  to  or  pro- 
duce the  disorder ;  in  discussing  the  local  causes  it  will  be  convenient  to 
associate  these  with  the  three  most  important  epochs  in  the  sexual  history 
of  woman,  which  are  (i.)  puberty,  and  the  early  years  of  menstrual  life  ; 
(ii.)  the  period  of  fertility;  and  (iii.)  the  menopause. 

(i.)  Menorrhagia  during  Puberty  and  the  early  years  of  Menstrual 
Life.  — From  what  has  already  been  said  it  may  be  gathered  that  in  young 
girls  the  causes  of  menorrhagia  are  for  the  most  part  of  a  general  kind. 
In  such  cases  local  examination,  except  under  the  most  urgent  circum- 
stances, is  to  be  avoided ;  and  treatment  ought  to  be  directed  to 
the  improvement  of  the  general  health,  and  especially  to  the  nervous 
and  hajmopoietic  systems.  If  in  such  cases  local  examination  is  indis- 
pensable it  should  be  made  by  the  rectum,  unless  vaginal  examination 
be  absolutely  imperative.  In  either  case  the  patient  should  be  anaesthe- 
tised. 

On  the  occurrence  of  every  menstrual  period,  a  condition  of  2k4cic 
hypercemia,  short  of  actual  inflammation,  with  its  various  stages  of  conges- 
tion, exudation,  and  resolution  or  suppuration,  is  established.  In  some 
cases  this  hyperaemia  is  so  much  exaggerated  as  to  give  rise  to  distressing 
symptoms — especially  to  menorrhagia — resembling  those  of  acuteinilani- 
mation  of  the  uterine  appendages.  This  event  is  not  an  uncommon 
result  of  the  reflex  irritation  which  accompanies  the  occurrence  of  the 
first  menstrual  period,  especially  in  the  case  of  girls  who  are  brought  up 
in  refinement,  and  who  are  overtaxed  at  school.  The  fact  that  local 
irritation  may  dangerously  increase  this  condition  of  hyperaemia  must 
not  be  overlooked. 

(ii.)  Menorrhagia  during  the  period  of  Fertility.  —  In  cases  of  this 
class  a  local  cause  is  more  commonly  to  be  found,  even  if  some  co- 
existing general  condition  accentuate  the  symptoms.  In  these  subjects 
local  examination  must  be  promptly  considered  and  unhesitatingly  urged: 
haemorrhage  is  too  dangerous  a  symptom  to  admit  of  delay. 


SYSTEM  OF  GYNECOLOGY 


As  in  the  former  class  of  cases  7)e?r('c  hyjjercemia  is  tlie  immediate  cause 
of  hgemorrhage.  Local  irritation  may  be  found  in  the  first  sexual  act  or 
in  excessive  indulgence.  Too  prolonged  a  lactation  acts  in  the  same  way, 
and  also  by  lowering  the  general  tone  of  the  system.  In  these  cases, 
unless  the  cause  be  removed,  the  line  between  mere  congestion  and  active 
inflammatory  changes  is  readily  overstepped. 

Fibroid  tumours,  which  are  a  very  common  cause  of  excessive  flow, 
probably  act  likewise  —  by  an  increased  vascular  supply  to  the  uterus,  and 
also  by  the  production  of  an  enlarged  and  inflamed  secreting  surface  : 
thus  we  find  excessive  bleeding  as  a  result  of  all  enlargements  of  the 
uterus  from  neoplasms  and  from  subinvolution ;  and  of  all  inflammatory 
conditions  of  the  peritoneal,  muscular,  or  mucous  coats.  Uterine  dis- 
placements, such  as  prolapse  and  flexions,  are  amongst  the  commonest 
causes  of  menorrhagia. 

The  excessive  haemorrhage  in  flexions  is  caused,  according  to  some 
observers,  by  a  temporary  accumulation  of  blood  in  the  cavity  of  the 
uterus,  which  causes  distension  and  an  increase  of  the  secreting  surface. 
As  more  fluid  accumulates  during  the  menstrual  period,  a  gush  occurs 
from  time  to  time,  so  that  the  patient  suffers  from  alternate  retention 
and  escape  of  menstrual  blood.  A  continuously  excessive  flow  of  blood 
is  rare  in  such  cases:  in  the  great  majority  menorrhagia  occurs  in 
gushes. 

Other  observers,  however,  believe  that  the  menorrhagia  in  cases  of 
flexion  is  simply  the  result  of  the  endometritis,  which  they  consider  to  be 
a  constant  accompaniment  of  displacements,  an  opinion  with  which  I 
entirely  concur.  Those  who  support  the  "  retention  "  theory  apply  it 
also  to  the  causation  of  the  menorrhagia  of  fibroids. 

Extra-uterine  inflamviations,  implicating  the  ovaries  and  tubes,  all  give 
rise  —  except  in  their  final  sclerotic  stage  —  if  not  to  metrorrhagia,  at 
least  to  menorrhagia.  Ovarian  tumours  may  have  the  sameeffect,  although 
not  nearly  so  markedly  as  uterine  tumours ;  in  fact  the  growth  of  many 
ovarian  tumours  does  not  affect  menstruation  at  all :  yet  disturbances 
of  the  circulation  in  the  ovaries  may  tend  to  produce  haemorrhage  from 
tlie  uterus  without  apparently  affecting  the  healthy  state  of  this  organ. 
Tumours  and  cysts  in  the  broad  ligaments  find  a  place  in  the  class  of  causes 
of  congestive  haemorrhage,  because  they  act  by  interference  with  the 
circulation  and  with  the  normal  position  of  the  uterus. 

Another  set  of  causes  are  those  which  directly  alter  the  condition  of 
the  surface  concerned.  Endometritis  has  already  been  mentioned  among 
the  inflammations  ;  but  there  is  a  special  form  of  endometritis,  known  as 
villous,  or  hmmorrhafjic  endometritis,  which  gives  rise  to  profuse  haemor- 
rhage, and  often  simulates  primary  cancer  of  tlie  fundus.  Cancer  both 
(;f  cervix  and  fundus,  polypi,  tubercular  and  other  ulcerations,  produce 
haemorrhage  in  great  measure  liecause  of  the  changes  they  effect  in  the 
mucous  membrane,  such  as  erosion  of  it,  and  consequent  implication  of 
the  superficial  and  sometimes  even  of  the  deep  blood-vessels. 

A  small  class  of  cases  may  be  mentioned,  mainly  consisting,  so  far  as  my 


DISORDERS   OF  MENSTRUATION  353 

experience  is  concerned,  of  soft,  fat,  flabby,  ansemic  women,  whose 
menstruation,  so  far  as  sanguineous  discharge  is  concerned,  is  entirely  in 
abeyance,  and  is  replaced  by  a  profuse  uterine  leucorrhoea.  This  may  be 
as  exhausting  as  profuse  haemorrhage,  and  is  often  accompanied  by 
colicky  pains.  I  have  never  seen  any  local  treatment  to  be  of  any  benefit 
in  such  cases.  Careful  dieting,  exercise,  salines,  and  a  course  of  Marienbad, 
constitute  the  most  satisfactory  treatment. 

Idiopatldc  Hcemorrhage.  —  There  is  one  form  of  haemorrhage  not  yet 
mentioned  which  may  occur  during  active  menstrual  life.  It  is  referred 
to  by  several  authors;  but  in  these  days  one  would  almost  hesitate  to 
mention  it  were  it  not  for  the  occurrence  of  cases  which  can  be  assigned 
to  no  other  class,  but  must  be  collected  under  some  such  name  as  Idio- 
pathic Haemorrhage.  I  am  strongly  of  opinion  that  it  must  be  extremely 
rare  for  haemorrhage  to  occur  with  no  local  or  general  lesion,  and  yet  the 
following  case,  Avhich  came  under  my  observation  some  years  ago,  is  very 
difficult  to  interpret  otherwise  :  — 

The  patient,  a  married  woman  with  four  children,  whom  I  had 
known  throughout  my  whole  professional  life,  had  menstruated  regularly, 
but  rather  profusely.  When  thirty -eight  years  old,  six  years  after  the 
birth  of  her  last  child,  she  was  seized,  during  the  course  of  a  menstrual 
period,  with  a  uterine  haemorrhage  so  severe  that,  in  the  middle  of  the 
night,  I  Avas  obliged  to  plug  her  vagina.  On  the  occasion  of  her  next 
menstruation  the  same  method  had  again  to  be  adopted  to  arrest 
htemcrrhage ;  and  this  had  to  be  carried  out  time  after  time  for  five 
months,  although  the  usual  appropriate  intermenstrual  treatment  by  hot 
douching,  ergot,  etc.,  was  strenuously  persisted  in ;  and  on  two  occasions 
her  uterus  was  curetted  and  styptics  applied  to  the  bleeding  surface. 
Each  successive  menstrual  period  left  her  more  and  more  exhausted. 
She  was  examined  frequentl}^,  with  the  utmost  care,  under  chloroform ; 
but  no  local  lesion  Avhatever,  nor  any  general  condition  could  be  found 
to  account  for  this  excessive  flow.  I  am  well  aware  that  even  the 
smallest  polypi  may  cause  profuse  and  even  fatal  haemorrhage ;  but  in 
this  case,  after  dilatation  of  the  cavity  of  the  uterus  and  the  most  careful 
examination,  I  could  find  no  trace  of  any  such  thing. 

During  the  course  of  a  menstrual  period  the  patient  died,  apparently 
of  syncope. 

An  autopsy  was  conducted  by  Dr.  Sims  Woodhead.  The  uterus 
was  examined  minutely,  yet,  except  that  it  was  slightly  enlarged  — 
to  the  extent  of  3  inches  —  and  contained  a  clot,  no  morbid  condition 
was  found  at  all.  There  was  no  neoplasm,  nor  any  abnormality  whatever 
in  any  of  the  coats  of  the  uterus.  In  the  left  ovary  there  was  a  large 
corpus  luteum.  The  thoracic  and  abdominal  viscera  were  pronounced 
to  be  normal.  The  symptom  in  this  case  might  have  been  attributed  to 
haemophilia;  but,  as  the  woman  had  presented  no  other  indicatitnis  of  this 
condition  either  in  her  earlier  or  her  later  life,  and  as  in  her  family  history 
there  was  nothing  to  suggest  such  a  diathesis,  there  was  no  course  open 
but  to  suppose  the  case  to  be  one  of  "Idiopathic  Menorrhagia." 

2  a 


354  SYSTEM  OF  GYNECOLOGY 

(iii.)  Menorrhagia  at  the  time  of  the  Menopause.  —  The  menopause 
is  a  period  which  is  characterised  by  the  occurrence  of  haemorrhages. 

The  climacteric  may  manifest  itself  in  three  special  ways :  (a)  the 
menses  may  cease  gradually ;  (6)  they  may  cease  only  after  a  long-con- 
tinued series  of  haemorrhages ;  (o)  they  may  cease  suddenly. 

It  is  with  the  second  of  these  varieties  that  we  are  more  especially 
concerned  at  present.  Whenever  at  the  menopause  haemorrhages  are 
profuse  very  careful  local  examination  should  be  made,  in  order  to 
ascertain  whether  the  condition  be  due  to  the  presence  of  a  neoplasm, 
to  some  other  local  cause,  or  to  general  causes.  A  most  important  point 
to  notice  is  that,  after  the  menopause  has  once  become  established,  post- 
climacteric haemorrhages  are  almost  invariably  due  to  a  local  lesion,  such 
as  senile  catarrh,  cancer,  or  the  presence  of  mucous  or  fibrous  polypi ; 
though  cases  are  recorded  in  which  this  symptom  has  been  due  to  sexual 
excitement.  But  it  must  always  be  kept  in  mind  that  women  of  a  gouty 
diathesis  not  only  often  menstruate  very  late  in  life,  but  have  recurrent 
post-climacteric  discharge  due  to  this  dyscrasia. 

This  is  not  the  place  in  which  to  discuss  the  differential  diagnosis  of 
cancer  from  senile  uterine  catarrh  or  fungous  granulations  on  the  uterine 
mucosa ;  but  the  importance  of  establishing  a  certain  diagnosis,  and  of  not 
postponing  a  local  examination  till  it  is  too  late,  cannot  be  too  strongly 
urged. 

The  above  discussion  of  uterine  haemorrhage  shows,  at  least,  the 
importance  of  regarding  it  rather  as  a  sign  than  as  a  disease.  While 
on  the  one  hand  the  cause  of  the  bleeding  in  each  case  must  be  carefully 
sought  out,  we  shall  remember  on  the  other  hand  that  in  young  unmarried 
women  the  most  common  causes  of  menorrhagia  and  metrorrhagia  are 
constitutional ;  in  fertile  women,  subinvolution,  fibroids,  and  displace- 
ments of  the  uterus ;  in  single  middle-aged  women,  fibroids ;  and  in 
women  between  forty  and  fifty,  either  the  usual  climacteric  haemor- 
rhages or  cancer  or  filjroids. 

The  symptoms  of  menorrhagia  are,  of  course,  the  symptoms  and 
signs  of  loss  of  blood  from  any  part.  It  may  occur  suddenly  and 
compromise  the  patient's  health  rapidly ;  or  it  may  occur  gradually  in 
increasing  quantity  month  by  month,  and  thus  induce  anaemia  with  its 
consequent  results. 

The  hfjein(jrrhage  of  a  so-called  haematocele  might,  no  doubt,  be 
described  with  some  truth  as  an  internal  menorrhagia.  More  commonly, 
however,  there  is  an  external  as  well  as  an  internal  haemorrhage ;  and  as 
haematocele  is  now  regarded  as  being,  in  the  great  majority  of  cases,  due 
to  an  early  ruptured  extra-uterine  gestation,  it  is  not  necessary  to  discuss 
the  suVjject  here. 

Treatment.  —  It  will  be  evident  from  the  great  diversity  of  causes 
that  the  ticatment  of  the  symptoms  under  consideration  must  have  a 
direct  reference  to  the  cause,  and  cannot  Ix;  indicated  on  general  lines  to 
suit  all  cases. 

As  we  have  to  decide  in  amenorrlujea  whether  it  be  advisable  or  not 


DISORDERS   OF  MENSTRUATION  355 

to  bring  about  the  luemorrhage  which  is  in  abeyance,  so  in  menorvhagia 
it  is  frequently  not  without  benefit  to  the  patient  that  she  should  lose 
more  blood  than  usual,  or  even  that  blood  should  flow  at  an  abnormal 
time,  so  long  as  the  loss  of  blood  does  not  markedly  depress  her  general 
health.  Wliere  salpingitis  or  ovaritis  or  other  inflammatory  condition 
exists  Avhich  produces  congestion  in  the  structures  about  the  uterus, 
the  local  loss  of  blood  may  often  relieve  the  pain  and  reduce  the  con- 
gestive condition.  So,  as  mentioned  above,  in  cases  of  backward  pressure 
producing  congestion,  bleeding  from  the  uterus  may  prevent  congestion 
or  bleeding  at  parts  where  it  would  be  much  more  dangerous. 

The  treatment  of  the  general  systemic  conditions  which  were  first 
discussed  obviously  consists  in  measures  tending  to  the  improvement  of 
the  general  tone.  Rest  in  bed  at  the  time  of  the  flow  is  frequently 
advisable  ;  because,  apart  from  the  fact  that  less  blood  is  likely  to  be  lost 
by  a  patient  lying  on  her  back  Avith  the  hips  raised  than  if  moving  about 
in  the  ordinary  way,  it  is  also  the  case  that  a  patient  lying  still,  with  the 
head  low,  can  lose  more  blood  with  less  bodily  harm  accruing  from  the 
loss. 

It  is  by  such  a  plan  as  this  that  the  menorrhagia  of  young  girls  must 
be  treated  before  we  resort  to  such  means  as  the  hot  douche,  or  indeed  to 
any  local  treatment.  Mental  and  bodily  rest,  with  careful  feeding,  are 
essential ;  and  so  is  the  administration  of  salines  and  tonic  medicines. 
The  following  prescription  is  so  commonly  used  in  my  ward  that  it  goes 
by  the  name  of  "The  Ward  Mixture"  —  I^  Magnes.  sulph.  3ss.-3j.,Quinin8e 
sulph.  gr.  iss.,  Ferri  sulphat.  gr.  v..  Acid  sulphuric  dil.  ^r^^x.,  Aq.  menth. 
pip.  ad  Sj. 

But  it  must  be  further  remembered  that  very  often  in  cases  where  the 
condition  may  seem  to  be  due  to  general  causes,  there  exists  also  a  local 
lesion  in  the  mucosa,  which  may  be  the  subject  of  fungoid  granulations. 
In  such  cases  curetting  is  often  of  great  avail.  This  operation,  one  of 
no  great  difficulty,  is  described  at  length  in  another  part  of  this  work 
{vide  p.  292,  et  seq.). 

Curetting  will  be  found  of  great  service  in  most  cases  of  menorrhagia 
and  metrorrhagia.  Some  authors,  indeed,  recommend  its  employment 
even  in  cases  where  in  the  actual  state  of  the  mucosa  it  does  not  appear 
to  be  required ;  in  cases,  for  instance,  where  the  luemorrhage  is  apparently 
due  to  nothing  more  than  an  iuflamed  condition  of  the  ovaries. 

With  regard  to  general  means  of  checking  haemorrhage  it  has  been 
found  that  not  much  is  to  be  gained  by  the  internal  administration  of 
drugs.  Out  of  a  very  large  number  of  drugs  which  have  the  reputation 
of  haemostatics  but  very  few  can  be  relied  upon:  of  these  the  foremost 
is  undoubtedly  ergot.  It  acts  by  causing  contraction  of  non-striped 
muscle,  and  thus  diminishing  the  calibre  of  blood-vessels :  in  the  uterus, 
moreover,  it  causes  contraction  of  the  network  of  muscular  fibres  which 
form  the  middle  coat,  and  constricts  the  vessels  which  pass  througli  that 
network ;  but,  so  far  as  my  experience  goes,  ergot  acts  very  inefficiently 
on  the  uterus  except  when  the  muscular  tissue  is  hypertrophied,  as  after 


356  SYSTEM  OF  GYNAECOLOGY 

labour  or  abortion ;  or  in  cases  of  fibroid.  Ergotine,  especially  in  con- 
junction with  strychnine  or  nux  vomica,  is  perhaps  the  most  efficient 
preparation.     Hydrastis  alone  or  with  ergot  is  often  of  service. 

Apart  from  its  use  in  abortion  or  parturition,  the  administration  of 
the  drug  must  be  long  continued  in  order  to  be  of  any  benefit.  Sulphuric 
acid  and  cannabis  indica  are  undoubtedly  useful  also  in  certain  cases. 

The  investigations  of  Dr.  Wright  of  jSTetley  give  promise  of  a  new 
remedy  applicable  in  certain  cases  of  menorrhagia  and  metrorrhagia, 
namely,  calcium  chloride.  The  chloride  is  a  convenient  salt  of  calcium, 
because  it  is  readily  soluble  in  water ;  and  calcium  acts  by  increasing  the 
coagulability  of  the  blood.  In  cases,  therefore,  where  the  coagulability 
of  the  blood  is  less  than  normal  (and  Dr.  Wright  describes  a  clinical 
method  of  estimating  this),  the  internal  administration  of  the  chloride  of 
calcium  in  doses  of  gr.  xv.  would  act  beneficially  by  bringing  the  coagu- 
labilit}'  up  to  the  normal  point.  It  has  been  tried  in  cases  of  uterine 
haemorrhage,  and  certainly  has  produced  good  results  in  some  of  them, 
both  as  a  draught  and  as  a  local  application. 

Of  local  cqyj^lications  none  can  bear  comparison  with  the  use  of  hot 
water  applied  in  the  form  of  vaginal  douches  at  a  temperature  of  120°  F. 
Indeed,  there  is  no  better  method  of  checking  a  long-continued  menstru- 
ation than  to  douche  the  patient  regularly  with  hot  water.  Many 
women  object  to  the  practice  ;  but  it  is,  nevertheless,  a  perfectly  safe 
and  satisfactory  way  of  stopping  a  long-continued  menstrual  discharge. 
Experiments  on  the  uterus  in  some  of  the  lower  animals  have  proved 
that  hot  water  as  a  muscular  stimulant  is  much  more  beneficial  than 
cold.  The  contraction  produced  by  hot  water  is  more  rapid,  and,  what 
is  more  important,  it  is  continued  for  a  longer  time  than  that  produced 
by  cold.  Moreover,  it  must  be  obvious  that  the  effect  of  a  hot  applica- 
tion on  the  system  must  be  much  better  than  that  of  one  which  re- 
moves a  considerable  amount  of  heat  from  a  body  already  reduced  by 
loss  of  blood. 

The  local  application  of  styptics,  especially  by  means  of  Playfair's 
probe  covered  with  cotton  wool  and  dipped  in  some  astringent  solution, 
is  often  of  the  utmost  value,  even  without  any  previous  curettage. 

Plugging  of  the  vagina  with  damp  antiseptic  wool  is  often  most  ser- 
viceable ;  in  exceptional  cases  the  uterus  may  be  packed  with  antiseptic 
gauze.  It  has  been  said  that  this  packing  may  result  in  a  dangerous 
regurgitation  of  fluid  through  the  Fallopian  tubes;  but  this  event, 
so  far  as  I  know,  is  extremely  rare,  and,  if  it  does  occur,  is  not  associated 
with  any  serious  symptoms.  Plugging  is  a  good  temporary  method  of 
checking  haemorrhage,  and  gives  time  for  the  application  of  measures  to 
restore  the  patient's  strength,  and  for  the  adoption  of  more  permanent 
remedial  means. 

ElacJ/ricAty.  — The  constant  current  in  the  treatment  of  menorrhagia 
seems  to  me  to  have  a  specially  beneficial  effe(;t  in  those  htemorrhages 
which  occur  at  or  near  the  menopause,  when  the  uterus  is  undergoing 
atrophic  changes.     It  is  also  useful  in  the  subinvolutions  of  actively 


DISORDERS   OF  MENSTRUATION  357 

fertile  women  —  although  I  am  obliged  to  add  that  in  two  cases  thus 
treated  subinvolution  fell  into  superinvolution,  with  subsequent  perma- 
nent sterility.  In  these  cases,  therefore,  this  method  of  treatment  must 
be  carried  out  with  special  precautions.  It  is  not  part  of  my  duty 
in  this  article  to  pronounce  upon  the  effects  of  the  continuous  current 
in  the  treatment  of  fibroids,  but  I  may  say  that  in  specially  selected 
cases  of  small  fibroids,  and  of  hsemorrhagic  endometritis,  this  method 
of  treatment,  if  carried  out  with  care  and  by  competent  hands,  frequently 
effects  a  temporary  and  occasionally  a  permanent  cure  [r/cZe  art.  "Elec- 
tricity in  Gynaecology  "]. 

Removal  of  the  Ovaries.  —  As  regards  the  treatment  of  menorrhagia, 
apart  from  any  uterine  neoplasm  or  general  condition,  by  removal  of  the 
ovaries,  I  will  give  here  the  reports  of  two  cases :  — 

1.  A  girl,  twenty  years  of  age,  unmarried,  suffered  for  three  years 
from  haemorrhage  to  such  an  extent  as  to  render  her  a  complete  invalid. 
When  she  came  under  my  observation  her  menstrual  flow  lasted  for 
fourteen  days.  At  the  end  of  her  period  she  was  bloodless,  and  subject 
to  frequent  faints.  The  uterus  was  curetted,  and  she  was  put  under 
long  courses  of  styptics  and  douching,  with  little  if  any  benefit.  As  a 
last  resource  removal  of  the  ovaries  was  considered  and  ultimately  carried 
out.  She  has  never  menstruated  since,  and  is  now  a  staff  nurse  in  a 
hospital  in  the  enjoyment  of  perfect  health. 

In  this  case  the  ovaries,  although  somewhat  enlarged  and  heavy, 
were  not  the  subjects  of  any  cystic  or  other  degeneration,  and  the  cause 
of  her  uterine  haemorrhage  was  not  otherwise  apparent. 

2.  Another  case  occurred  of  a  somewhat  similar  character.  A  young 
lady  of  twenty-five  had  been  married  for  four  years,  and  was  sterile.  She 
bled  so  profusely  at  her  periods,  and  occasionally  intermenstrually,  that 
she  was  practically  bedridden.  The  uterus  was  apparently  normal.  She 
had  no  general  disorder,  and  after  the  usual  treatment  by  curetting, 
styptics,  and  hot  douching  for  a  long  time,  no  improvement  resulted. 
After  careful  consultation,  and  with  the  concurrence,  of  course,  of  her 
friends,  the  ovaries  Avere  removed.  Since  that  time,  ten  years  ago, 
menstruation  has  not  returned,  and  she  has  been  in  the  enjoyment  of 
excellent  health.  The  ovaries,  as  in  the  former  case,  were  simply  en- 
larged and  heavy. 

In  neither  of  these  cases  was  there  any  reason  to  suppose  that  an}^ 
sexual  irritation  existed.  Now,  although  I  am  very  far  from  recommend- 
ing such  a  course  for  freqiient  adoption,  I  mention  these  cases  as  extreme 
ones,  needing  extreme  measures.  No  operation  in  gyna?cology  requires 
to  be  more  safeguarded  than  that  for  removal  of  the  ovaries.  It  is, 
unfortunately,  an  easy  operation,  and  one  far  too  frequently  performed. 
I  mention  the  above  cases  only  as  exceptional  ones. 

The  treatment  of  uterine  displacements,  cancer,  fibroids,  and  all 
other  local  conditions  which  give  rise  to  haemorrhage,  must  be  sought 
for  in  other  parts  of  the  System. 


358  SYSTEM  OF  GYNAECOLOGY 

Dtsmexorrhcea.  —  All  women,  even  while  enjoying  good  health,  feel 
"  unwell,"  as  they  themselves  call  it,  at  the  menstrual  period.  They  ex- 
perience some- pelvic  discomfort  or  inconvenience  associated  with  a  general 
malaise,  a  few  indefinite  pains  in  the  back  and  loins,  and  a  certain  irrita- 
bility of  temper ;  that  a  woman  should  not  be  thus  affected  would  be  almost 
an  abnormality.  However,  I  do  not  for  a  moment  deny  that  some  women 
menstruate  with  no  trace  of  suffering  whatever,  the  presence  of  the 
discharge  being  only  an  inconvenience.  It  is  easy  to  understand  the 
'•normal"  discomfort  if  the  nature  of  the  function  of  menstruation  is 
considered.  It  is  impossible  to  suppose  that  the  various  changes, 
especially  the  congestion,  which  occur  during  the  different  stages  of  the 
process  of  normal  menstruation  should  take  place  without  giving  rise  to 
a  certain  amount  of  pelvic  and  general  discomfort.  But  the  difficulty 
lies  in  fairly  estimating  the  suffering  of  the  individual,  and  in  determin- 
ing when  the  disorder  has  ceased  to  be  physiological  and  has  become 
pathological.  The  sensitiveness  of  the  nervous  system  in  women  varies 
so  much  that  what  is  described  by  some  as  an  "  inconvenience  "  by  others 
is  called  "  discomfort " ;  what  is  to  some  "  discomfort "  to  others  is 
'•'  pain  "  ;  and  yet  others,  again,  who  call  their  suffering  "  a  little  pain  " 
endure  as  much  as  many  who  describe  their  sufferings  as  '•  agonising  "  or 
"  excruciating."  One  must,  therefore,  draw  a  line  of  demarcation  between 
the  mere  discomfort  of  menstruation  —  no  matter  how  it  is  described  by  the 
sufferer  —  and  genuine  dysmenorrhoea,  which  is  graver  pain  occurring  at 
or  about  the  menstrual  epoch ;  pain  so  severe  as  to  interfere  with  health, 
with  work,  or  with  pleasure.  It  is  not  easy  to  lay  down  a  hard  and  fast 
rule  in  the  estimation  of  pain,  which,  after  all,  is  a  symptom  which  does 
not  directly  appeal  to  any  of  the  senses  of  the  physician.  With  limita- 
tions, however,  it  may  be  concluded,  in  the  case  of  a  poor  woman  who 
has  to  work  for  her  daily  bread,  that  if  her  dysmenorrhoea  is  not  suffi- 
cient to  lay  her  up  and  so  to  withdraw  her  from  her  duties,  then  her 
suffering  requires  no  special  local  treatment;  in  the  well  to  do,  if 
the  pain  does  not  deprive  the  sufferer  of  her  social  enjoyments  and 
amusements,  it  likewise  calls  for  no  special  local  treatment.  In  these 
cases  even  a  vaginal  examination,  at  any  rate  in  the  unmarried,  should 
not  be  undertaken,  or  at  all  events  not  without  a  prolonged  trial  of  general 
remedies  and  management.  But  there  is  no  doubt  a  very  large  number 
of  women  who  constantly  demand  and  deserve  our  attention  on  account  of 
menstrual  suffering.  Their  pain  is  not  the  mere  discomfort  of  all  women, 
nor  tlie  temporary  severe  pain  of  many,  but  a  {U'ohMiged  agony  ;  in  some 
cases  so  extreme  as  to  render  life  a  burden  for  years.  No  sooner  has  the 
pain  of  one  epoch  passed  than  they  begin  to  dread  with  horror  the  next; 
and  so  life  is  rendered  miserable.  The  disease,  or  rather  the  symptom, 
sehlom  leads  dircic.tly  to  death  ;  but  it  does  interfere  to  a  very  large  extent 
with  fertility,  health,  and  happiness.  With  such  a  state  of  things  one 
has  frffjuently  to  deal  in  practice,  perhai)S  more  frequently  than  with 
any  other  disorder  of  menstruation  ;  and,  fui'tlier,  the  reH(!x  and  sympa- 
thetic disordfirs  associated  with  dysincnorrhoia  —  the  mental  and  nervous 


DISORDERS   OF  MENSTRUATION  359 

derangements  —  are  many.  These  neuroses,  due  mainly  to  changes  in 
the  ovaries,  are  well  recognised,  and  must  be  carefully  considered  in 
dealing  with  dysmenorrhoea. 

There  is  no  very  definite  relation  between  the  amount  of  flow  and 
the  degree  of  dysmenorrhoea :  although  in  many  of  the  spasmodic  and 
membranous  forms,  as  we  shall  see  further  on,  the  discharge  is  often 
scanty,  yet  it  is  often  profuse  in  the  ovarian  and  tubal  forms,  in  both  of 
which  the  pain  is  equally  well  marked.  Perhaps,  on  the  whole,  uterine 
dysmenorrluea  is  more  marked  when  the  menstruation  is  scanty  than 
when  it  is  profuse. 

In  some  women  the  dysmenorrhoea  begins  with  puberty  and,  unless 
active  treatment  is  adopted  or  pregnancy  occurs,  it  continues  all  through 
adult  life :  in  others  it  arises  only  after  some  distinct  exciting  cause, 
such  as  a  chill,  or  under  conditions  which  give  rise  to  inflammatory  or 
other  changes  in  the  uterus  or  its  appendages.  No  doubt  dysmenorrhoea 
is  commoner  among  unmarried  women,  but  sometimes  it  sets  in  only 
after  marriage.  When  met  with  in  married  women  it  is  frequently 
associated  with  sterility  ;  and  it  is  certainly  less  frequent  among  parous 
women  than  in  the  nulliparous. 

Dysmenorrhoea  and  Sterility.  —  Some  relation  between  dysmenorrhoea 
and  sterility  has  been  observed  frequently  enough.  In  many  cases  the 
association  is  accidental.  So  far,  indeed,  as  I  am  able  to  judge,  the 
association  of  dysmenorrhoea  with  sterility  is  not  so  close  as  is  generally 
supposed. 

Kehrer,  who  has  gone  into  this  matter  at  some  length,  has  shoAvn 
that  a  history  of  painful  menstruation  before  marriage  is  only  slightly 
more  common  in  sterile  than  in  fertile  women.  Kammerer  gives  a  table  of 
408  cases  of  sterility,  in  67  of  which  dysmenorrhoea  was  a  prominent  symp- 
tom ;  Jackson  gives  a  table  of  72  cases  of  sterility,  in  16  of  which  dys- 
menorrhoea was  a  prominent  symptom.  Certainly,  on  reflecting  upon 
my  own  experience,  I  should  not  be  inclined  to  give  dysmenorrhoea  a 
prominent  place  in  relation  to  sterility.  Obstructive  dysmenorrhoea, 
putting  the  term  conversely,  and  regarding  various  conditions  of  the 
uterus  as  obstacles  to  conception,  scarcely  appears  to  me  to  have  any 
foundation :  in  fact,  as  Jackson  says,  "  The  obstacles  which  are  over- 
come by  spermatozoa  in  their  progress  towards  the  uterine  cavity  are, 
to  say  the  least,  remarkable." 

The  view  which  commends  itself  to  me  is  that,  in  cases  of  dysmenor- 
rhffia  associated  with  sterility,  the  explanation  of  both  conditions  is  to  be 
sought  for  rather  in  general  congestion  of  the  pelvic  organs,  more  espe- 
cially of  the  endometrium,  than  in  any  mechanical  cause.  The  dys- 
menorrhoea is  accounted  for  In''  a  hyperaemia;  and  the  sterility,  not  by 
any  mechanical  interference  with  conception,  but  rather  by  some  con- 
dition of  the  endometrium  which  interferes  with  the  continuance  of 
gestation.  In  other  words,  the  dysmenorrhoea  is  due  to  congestion  of 
the  uterus  associated  at  times  Avith  spasm  of  the  os  uteri  internum  ;  and 
the  sterility  to  a  hyperasmic  and  hyperaesthetic  state  of  the  endometrium. 


36o  SYSTEM  OF  GYNECOLOGY 

Such  a  view  as  this  explains  how  it  is  that,  after  treating  various 
conditions  of  apparent  meclianical  obstruction  —  such  as  anteflexion, 
stenosis,  and  so  on  —  the  sterilitj^  continues.  A  very  large  number  of 
the  processes  concerned  in  generation  are,  no  doubt,  wholly  mechanical ; 
and  it  is  not  surprising,  therefore,  that  in  cases  of  sterility  which  present 
some  apparent  obstacle  of  a  mechanical  character,  this  obstacle  should 
be  promptly  accepted  as  the  efficient  cause,  and  mechanical  means  adopted 
for  its  relief.  It  is  certain  that  the  cure  of  an  anteflexion  or  a  retro- 
flexion, or  in  other  words  the  removal  of  causes  apparently  mechanical, 
has  resulted  in  the  cure  of  dysmenorrhoea ;  and  we  have  learned  clini- 
cally that  it  has  sometimes  been  followed  by  a  pregnancy.  Far  oftener, 
however,  these  mechanical  means,  while  relieving  the  dysmenorrhoea, 
have  failed  entirely  to  remove  the  sterility,  —  failed,  no  doubt,  because 
they  did  not  remove  some  condition  other  than  the  mere  narrowing  of 
the  cervical  canal ;  such  a  condition  seems  to  me  to  be  a  morbidly 
hypersemic  state  of  the  endometrium,  which  renders  the  grafting  of  the 
ovule  an  impossibility. 

Tlie  Varieties  of  Dysmenorrhoea.  — The  classifications  given  by  differ- 
ent authors  are  endless,  but  many  of  them  have  been  framed  upon  erro- 
neous notions  of  the  nature,  firstly,  of  menstruation,  and,  secondly,  of 
dysmenorrhoea.  For  example,  many  arrangements  have  been  suggested 
on  a  purely  mechanical  or  obstructive  view  of  the  causation —  as  if  due 
to  displacements,  stenosis  of  the  cervix,  and  so  on  ;  and  while  these  are, 
no  doubt,  elements  in  the  causation,  yet  some  deeper  cause  underlying  it 
all,  underlying  all  the  varieties  and  forms,  must  be  looked  for.  The 
initial  difficulty  in  discussing  dysmenorrhoea  lies  in  our  ignorance  of  the 
ordinary  physiology  of  menstruation.  I  cannot  here  discuss  the  various 
theories  of  menstruation,  they  must  be  sought  elsewhere ;  but  I  may 
say  bi'iefly  that  in  all  varieties,  no  matter  where  the  exact  origin  of 
the  pain  may  be,  the  essence  of  dysmenorrhoea  is  congestion. 

It  is  easy  to  make  a  primary  classification  of  the  varieties  of  dysmen- 
orrhoea—  one  which  probably  no  one  will  dispute  —  namely,  to  divide 
the  various  forms,  clinically,  into  (I.)  Uterine ;  (II.)  Extra-uterine.  This 
classification  is  based  upon  a  clinical  consideration  of  the  nature  of  the 
pain,  and  of  the  organs  primarily  affected. 

Others  have  classified  the  varieties  as  primary  and  acquired;  and  this 
arrangement  no  doubt  is  occasionally  useful.  Primary  dysmenorrhoea 
is  that  form  which  sets  in  at  early  puberty  and  continues  into  adult  life. 
It  is  found  associated  with  defective  development,  and  leads  subse- 
quently to  the  spasmodic  form  of  dysmenorrhoea.  Acquired  dysmenor- 
rhoea is  found  in  young  women  after  attacks  of  the  exanthemata,  or 
after  chills ;  in  parous  women  it  follows  sepsis  after  an  abortion  or  a 
full  term  labour,  and  so  on. 

It  is  not  now  matter  for  dispute  that  a  uterine  and  an  extra-uterine 
form  of  dysmeiiorrhfea  exist;  ])ut  difficulties  arise  as  we  recognise  tliat 
the  varieties  are  very  often  mixed;  and  still  greater  difficulties  are  met 
with  when  we  attempt  to  arrange  the  different  causes,  especially  of  uter- 
ine dysmenorrhoea.    The  difficulty,  however,  does  not  lie  in  the  clinical 


DISORDERS    OF  MENSTRUATION  361 

distinction  of  the  forms,  but  rather  in  the  proper  naming  of  each  kind. 
Different  minds  are  apt  to  associate  different  meanings  with  the  same 
word,  and  hence  confusion  arises. 

Four  factors,  roughly  speaking,  are  concerned  in  the  production  of 
dysmenorrhoea :  1st,  Some  morbid  condition  in  the  shedding  off  of  the 
mucous  membrane  in  whole  or  in  part,  seen  in  its  most  pronounced  form 
in  membranous  dysmenorrhoea.  In  a  state  of  health  the  process  of  dis- 
integration, I  apprehend,  takes  place  with  little  trouble;  but  if,  on  the 
other  hand,  from  some  such  cause  as  the  changes  produced  in  the  raucous 
membrane  by  long-standing  inflammation,  the  process  be  retarded,  centres 
may  be  furnished  for  the  formation  of  clots ;  and  these  increasing  in  size 
and  becoming  foreign  bodies,  lead  to  violent  intermittent  contractions. 
2nd,  The  consequent  difficulty  and  pain  of  the  uterine  contraction ;  wiiich 
are  still  more  marked  if  the  uterine  muscle  be  the  seat  of  any  inflam- 
matory change.  3rd,  Some  obstruction  to  the  outflow  of  the  uterine 
discharge,  leading  subsequently  to  retention  and  congestion.  4th,  and 
lastly,  these  local  conditions,  themselves  a  source  of  local  pain  and 
discomfort,  may  be  aggravated  in  each  individual  case,  according  to  the 
nervous  constitution  of  the  sufferer.  In  other  words,  the  whole  condition 
is  one  of  hypersemia  and  hypersesthesia. 

I.  Uterine  Dysmenorrhoea.  —  A.  From  defective  development  and  obstruo- 
tion.  —  The  first  class  of  cases  of  uterine  dysmenorrhoea  to  which  I  would 
refer  is  that  associated  with  defective  development.  The  uterus  after 
puberty  in  such  cases  continues  in  a  more  or  less  infantile  condition  : 
such  a  uterus  is  frequently  found  in  young  chlorotic  girls,  and  it  is 
associated  with  a  marked  form  of  dysmenorrhoea.  An  undeveloped  organ 
performs  its  function  badly,  and  the  uterus  is  no  exception  to  the  rule. 
Ill  development  has  been  specially  studied  by  Sir  John  Williams,  and  the 
connection  between  this  condition  and  dysmenorrhoea  has  been  particu- 
larly emphasised.  It  has  further  been  pointed  out  that  the  younger  the 
sufferer  from  painful  menstruation  the  more  defective  the  development 
of  the  pelvic  organs. 

Into  this  class  of  cases  we  may  fairly  admit  the  dysmenorrhoea  of 
young  women  who  suffer  from  a  displacement,  especially  from  anteflexion 
of  the  uterus.  The  position  is,  however,  nothing  more  than  the  per- 
sistence of  the  normal  condition  of  the  child ;  in  short,  it  is  a  defect  of 
development.  This  unripeness  of  the  uterus  may  show  itself  in  other 
ways  than  in  a  flexion  of  the  body  on  the  cervix.  Frequently  stenosis 
of  the  OS  is  an  indication  of  ill  development ;  and  when  either  a  flexion 
or  a  stenosis,  or  both  exist,  dysmenorrhoea,  frequently  called  obstructive 
or  mechanical,  is  the  most  prominent  symptom  of  the  existing  con- 
dition. But  while  not  denying  the  possibility  of  a  purely  obstructive 
dysmenorrhoea  from  narrowing  of  either  os,  or  of  the  whole  cervical 
canal,  I  venture  to  say  that  uncomplicated  cases  are  very  rare.  ^Eechani- 
cal  obstruction  causing  ]iain  is  possible  at  the  beginning  of  menstrual 
life ;  but  ere  long  a  secondary  congestion,  and  even  actual  inflammatory 
changes  from  retention  of  menstrual  flow,  are  an  inevitable  result. 


362  SYSTEM   OF  GYNECOLOGY 

There  are  many  objections  to  the  "mechanical  theor}'"  of  dysmenor- 
rhcea.  It  has  been  nrged  that  if  blood  can  flow  through  a  capillary  tube 
no  OS  or  cervical  canal,  however  narrowly  contracted,  can  offer  a  positive 
obstruction ;  and  it  is  further  pointed  out  that  many  women  with  most 
marked  flexion  and  a  pin  hole  os  menstruate  with  no  abnormal  dis- 
comfort. These  and  other  objections  are  no  doubt  potent  in  many  cases, 
and  I  believe  that,  in  a  case  of  any  standing,  an  inflammatory  condition 
must  be  superadded  to  the  obstruction ;  so  that  most  of  these  cases  would 
be  grouped  in  the  second  class  of  uterine  dysmenorrhoea  to  be  mentioned 
later.  I  do  not  Avish  it  to  be  supposed  that  cases  are  frequent  in  which 
the  only  signs  to  account  for  the  dysmenorrhoea  are  a  flexion  or  a 
stenosis  without  any  indication  of  excessive  congestion  or  inflamma- 
tion to  account  for  the  symptom.  The  chief  symptom  of  congenital 
anteflexion  is  undoubtedly  dysmenorrhoea  characterised  by  violent  pains 
in  the  loins  while  the  blood  distends  the  body  of  the  uterus  —  the  part, 
that  is,  above  the  point  of  flexion ;  suddenly  the  obstacle  is  overcome 
and  the  collected  menses,  partly  fluid  and  partly  in  clots,  are  expelled. 
The  purely  mechanical  theory  of  dysmenorrhoea,  since  it  was  made 
known  by  Simpson  and  Sims,  has  been  accepted  by  most  authors.  It 
is  rejected,  however,  by  Champneys  and  by  Fritsch ;  the  latter  explains 
the  pain  as  due  to  irritation  from  congestion ;  the  abnormal  vascular 
tension,  the  result  of  the  interference  with  the  circulation  in  the  vessels 
at  the  point  of  flexion,  irritates  the  nerves  of  the  uterus  and  so  causes 
the  pain.  However,  the  paroxysmal  and  alternating  character,  both 
of  the  pains  and  of  the  discharge,  almost  compel  one  to  consider  the 
obstruction  to  an  easy  flow  as  of  vital  importance. 

It  has  even  been  suggested  that,  as  the  result  of  anteflexion  and  con- 
sequent obstruction,  a  few  drops  of  blood  are  every  month  forced  along 
the  Fallopian  tabes  into  the  peritoneal  cavity,  and  give  rise  to  a  periodic 
and  miniature  hcematocele.  These  small  internal  haemorrhages  are  con- 
sidered by  some  observers  to  be  the  cause  of  the  posterior  perimetritis 
which  sometimes  accompanies  anteflexions  ;  and  this  inflammatory  con- 
dition would  account  for  the  acute  febrile  phenomena  with  which  the 
dysmenorrhfea  of  anteflexion  is  sometimes  associated. 

B.  Spasmodic  and  Inflammatory.  —  Cases  in  the  previous  group,  as 
age  advances,  frequently  merge  into  a  second  class  of  uterine  dysmenor- 
rhoea, namely,  the  spasmodic  and  inflammatory. 

The  continuance  of  the  mechanical  form  leads,  sooner  or  later,  to 
hyperijemia  and  thence  to  subacute  inflammation;  thus  the  so-called 
"  spasmodic  dysmenorrhoea"  is  established.  This  very  well  recognised 
form  of  dysmenorrhcxia  is  the  result  of  spasm,  not  only  of  the  uterus,  but 
of  the  OS  internum,  occurring  in  an  organ  subacutely  inflamed.  Whether 
the  subacute  inflammation  be  due  to  the  retention  of  clots  in  a  displaced 
uterus,  which  act  iis  foreign  bodies  and  cause  congestion  and  spasm  ;  or 
whether  it  be  due  to  an  alteration  in  the  circulation  of  the;  uterus  caused 
by  the  flexion,  is  a  matter  which  scarcely  admits  of  deflnite  settlement. 
Though  this  form  may  sometimes  be  primary,  due  to  any  cause  which 


DISORDERS    OF  MENSTRUATION'  363 


may  lead  to  accidental  congestion  or  inflammation  of  the  uterus,  it  is, 
as  we  have  seen,  usually  secondary  to  a  dysmenorrhoea,  arising  from 
defective  development  or  simple  obstruction. 

The  dysmenorrhoea  associated  with  fibroid  tumours  of  the  uterus  may 
also  be  included  in  this  class.  Ko  doubt  many  of  these  cases  may  be 
attributed  to  the  obstruction  which  the  tumour  offers  to  the  easy  escape 
of  blood ;  but  in  most  of  them  the  inflamed  condition  of  the  uterine 
mucosa  which  invariably  accompanies  the  neoplasm  is  the  cause  of  the 
suffering. 

Many  describe  as  "constitutional"  a  gouty,  a  rheumatic,  and  a 
neuralgic  form  of  menstrual  pain.  But  all  these,  I  believe,  are  associated 
at  least  with  congestion  of  the  uterus,  and  many  with  a  marked  sub- 
acute form  of  inflammation ;  they  are  therefore  included  in  the  present 
class.  The  dysmenorrhoea  in  such  cases  is  simply  the  evidence  of  an 
inflammation  similiar  to  that  which  occurs  in  other  organs  of  those  who 
are  the  subjects  of  such  diatheses.  That  this  kind  of  dysmenorrhoea  is 
common  there  can  be  no  reasonable  doubt.  How  else  are  we  to 
account  for  the  persistence  of  dysmenorrhoea  in  members  of  the  same 
family  ?  How  else  are  we  to  account  for  the  persistence  of  sterility 
associated  with  dysmenorrhoea  in  members  of  the  same  family  ?  I  have 
frequently  seen  families  in  which  the  daughters  were  all  dysmenorrhoeic 
and  all  sterile.  Now  in  such  families  I  believe  that  the  dysmenorrhoea 
is  due  to  gouty  or  rheumatic  inflammation  of  the  endometrium,  with  a 
resulting  spasm  of  the  os  uteri  internum  ;  and  that  the  sterility  is  due, 
not  to  interference  with  conception,  but  rather  to  the  congestion  of 
the  mucous  membrane  which  thus  forms  a  bad  nidus  for  gestation. 

Symi^toms. — The  situation  of  the  pain  is  usually  in  the  neighbour- 
hood of  the  pubes.  The  pain  is  described  by  the  sufferer  as  "  bearing 
down,"  and  comes  on  in  spasms,  intermittently.  It  resembles  colic  of  a 
severe  type.  The  pain  lasts  for  the  first  day,  and,  indeed,  until  the  dis- 
charge is  distinctly  established,  when  relief  is  obtained.  The  actual  flow 
may  be  scanty,  but  it  is  generally  accompanied  by  clots.  The  severity  of 
the  pain  varies  ;  it  is  sometimes  so  severe  as  to  be  associated  with  nausea, 
vomiting,  and  utter  prostration.  Occasionally  the  suffering  recurs  on  the 
second  or  third  day,  owing  no  doubt  to  the  attempts  of  the  uterus  to 
expel  accumulated  clots. 

Spasmodic  dysmenorrhoea  has  no  tendency  to  spontaneous  cure,  but. 
unless  the  patient  be  subjected  to  appropriate  treatment  or  become 
pregnant,  it  becomes  more  and  more  aggravated  as  time  goes  on.  When 
pregnancy  does  occur,  and  goes  on  to  full  term,  the  patient  is  usually 
cured. 

The  diarinosis  of  these  cases  must  be  accurately  made,  because  upon 
accurate  diagnosis  depends  etiicient  treatment. 

Of  course  it  occasionally  happens  that  a  spasmodic  dysmenorrhoea  is 
associated  with  other  kinds;  but  when  the  condition  is  simjile  it  is  to 
be  recognised :  1st,  By  the  fact  that  the  pain  occurs  in  the  first  twenty- 
four  or  forty-eight  hours  of  the  menstrual  period ;  2nd,  that  there  is  no 


364  SVST£M   OF  GYN,'€,COLOGY 

appreciable  change  in  the  uterine  appendages  ;  and,  3rd,  tliat  the  uterus 
is  freely  movable,  and  usually  flexed  either  anteriorly  or  posteriorly. 
When  such  a  state  of  things  is  ascertained,  treatment  is  satisfactory. 

Treatment.  —  This  resolves  itself  into  —  1.  Palliative,  which  applies 
to  all  forms  of  dysmenorrhoea ;  2.  Radical. 

1.  Palliative  Treatment.  —  This  consists,  first  of  all,  in  dealing  with 
any  general  condition,  such  as  anaemia,  gout,  or  rheumatism, — mala- 
dies to  be  treated  by  iron  and  arsenic,  colchicum,  and  the  salicylates 
respectively.  In  the  second  place,  the  treatment  of  the  actual  pain 
is  to  be  conducted  first  of  all,  and  mainly,  by  pelvic  depletion. 
Anything  that  depletes  the  pelvis  proportionately  diminishes  the 
hyperaemia  upon  which  the  pain  depends  ;  and,  therefore,  the  free  use  of 
salines  before  the  periods  is  of  the  utmost  value.  Very  often,  in  anajmic 
women,  a  continued  use  of  chlorate  of  potash,  iron,  and  actaea  racemosa, 
used  in  combination  for  a  week  before  and  during  the  period,  will  give 
much  relief. 

For  the  actual  suffering,  antipyrin,  phenacetin,  and  the  other  coal  tar 
derivatives  of  this  group,  will  be  of  service ;  pulsatilla,  also,  either  as  the 
tincture  in  five  minim  doses  every  hour,  or  combined  with  caulophyllin, 
is  most  useful ;  in  my  experience  it  has  been  eminently  satisfactory. 
When  the  pain  is  excessive  nitrite  of  amyl  or  nitro-glycerine  may  be 
administered  with  advantage. 

Such  peripheral  sedatives  as  cicuta  verrosa  and  castor  are  useful. 
Undoubtedly  opium  and  alcohol  give  the  most  prompt  and  efficient 
relief ;  but  their  temporary  employment  may  become  a  permanent  habit, 
and  therefore  they  are  to  be  employed  with  the  utmost  caution. 
Diaphoretics,  warm  hip  baths,  sinapisms,  and  hot  drinks  will  all  relieve 
the  distress  to  a  certain  extent. 

2.  Radical  Treatment.  — In  cases  of  defective  development  in  young 
girls  nothing  beyond  palliative  treatment  is  to  be  attempted.  But  when 
the  case  is  obstructive,  or  primarily  or  secondarily  spasmodic,  then  the 
local  treatment  is  clear  and  definite  ;  and,  as  a  rule,  if  undertaken 
carefully,  is  entirely  satisfactory.  If  the  manipulations  to  be  described 
are  carried  out  with  careful  and  antiseptic  precautions,  and  there  be  no 
peri-uterine  disturbance,  an  absolute  cure  can  in  most  cases  be  anticipated. 

In  dealing  with  a  case  of  spasmodic  dysmenorrhoea  which  resists  the 
ordinary  palliative  treatment,  and  where  the  symptoms  are  sufficiently 
severe,  a  vaginal  examination  ought  to  l)e  made  under  chloroform  ;  if  the 
uterus  be  found  freely  moval)le  —  anteflexed  or  retrofiexed  as  the  case  may 
be — and  the  uterine  appendages  healthy,  the  indications  for  treatment  are 
oVjvious.  There  are  several  alternative  means :  the  first  and  best  is  as 
follows.  Under  anaesthesia  the  cervix,  fixed  by  a  volsella,  should  be 
gradually  dilated  by  a  scries  of  bougies,  either  metallic  ones  or  those 
of  Hegar;  in  a  few  cases  the  mere  passage  of  the  uterine  sound 
immediately  before  a  period  is  sufficient  to  relieve  the  pain.  Secondly, 
as  an  alternative,  the  cervix  may  be  rapidly  dilated  ])y  Sims'  or  Ellinger's 
dilators.    lOithor  <jf  these  methods  will  in  most  cases  be  found  satisfactory. 


DISORDERS   OF  MENSTRUATION  365 

The  operation,  however,  has  to  be  repeated  frequently.  Thirdly,  if  the 
tiexiou  backwards  or  forwards  be  very  acute,  a  stem  pessary  may  be 
found  useful.  I  am  well  aware  of  the  risk  of  using  these  instruments, 
but,  with  due  care  and  precaution,  excellent  results  may  be  obtained, 
even  in  some  persistent  cases. 

It  is  essential  that  immediately  after  the  introduction  of  the  intra- 
uterine pessary  the  patient  should  be  kept  in  bed  and  carefully  observed 
for  some  days.  As  a  rule  the  introduction  is  speedily  followed  by  spas- 
modic pains  in  the  uterus,  but  these  soon  subside.  Occasionally,  however, 
a  more  serious  pain  results,  that  of  pelvic  peritonitis  ;  and  should  there 
be  the  slightest  indication  of  this  the  stem  should  be  removed  instantly. 
It  is  almost  impossible  to  determine  beforehand  whether  a  uterus  will 
tolerate  the  introduction  of  a  foreign  body.  Some  wombs  are  extremely 
tolerant,  others  will  not  endure  the  slightest  mechanical  interference 
without  inflammatory  reaction.  Before  one  ventures  to  use  a  stem 
pessary  it  should  be  determined  that  the  uterine  appendages  are  per- 
fectly healthy ;  the  personal  equation  of  the  uterus  also  should  be  esti- 
mated, so  far  as  possible,  by  the  frequent  passage  of  the  sound.  If  the 
stem  pessary  can  be  worn  without  discomfort,  the  patient  may  get  up 
after  a  few  days,  and  after  a  week  or  two  a  larger  stem  may  be  substi- 
tuted. The  cases  which,  as  a  rule,  are  most  satisfactorily  treated  by 
this  method  are  those  of  aggravated  congenital  flexion.  The  patient 
should  not  be  subjected  to  the  risk  of  a  stem  pessary  until  all  other 
means  have  failed,  and  then  only  with  the  utmost  caution. 

One  other  method  of  treatment  of  this  form  of  dysmenorrhoea 
remains ;  but  it  may  be  dealt  with  shortly,  as  within  recent  years  it 
has  fallen  into  desuetude,  at  any  rate  in  this  country. 

Sir  James  Simpson  was  the  first  to  advocate  the  division  of  the  cervix ; 
and  he  was  led  to  adopt  this  method  b}^  the  common  observation  that 
dysmenorrhcea  is  much  less  frequent  in  parous  women  than  in  the  nulli- 
parous.  Acting  on  the  supposition  that  the  shape  of  the  cervical  canal 
is  important  in  the  causation  of  the  menstrual  pain,  he  so  divided  the 
lips  of  the  cervix  that  its  condition  in  a  nou-parous  woman  approximated 
to  that  of  one  who  had  borne  children.  The  operation  is  performed  with 
the  metrotome  or  with  Kiiehenmeister's  scissors. 

Sometimes  the  operation,  instead  of  being  a  bilateral  one  as  advo- 
cated by  Simpson,  is  single;  and  either  posterior  or  anterior  according 
to  the  flexion  :  the  object  in  view  being  to  straighten  the  canal  distorted 
by  the  displacement.  But  the  operation  of  division  of  the  cervix  is  by 
no  means  a  safe  one.  Putting  aside  the  risk  of  sepsis,  the  haemorrhage 
is  frequently  most  alarming,  so  much  so  that  if  it  is  to  be  performed, 
previous  ligation  of  uterine  arteries,  or  at  least  of  the  lower  branches, 
is  now  considered  necessary.  Very  few  operators,  however,  now  em- 
ploy the  method. 

For  the  treatment  of  uterine  dysmenorrhrea  bi/  elect ricit;/,  the  reader 
is  referred  to  the  article  by  Dr.  Milne  Murray  in  another  part  of  this 
work.     The  third  form  of  uterine  dysmenorrhoea  is  that  known  as  — 


366  SYSTEM  OF  GYNMCOLOGY 

C.  JlembranoHs  Dysmenorrlioea.  —  Morgagni  (23)  first  noticed  a  kind 
of  dysmenorrhoea  in  wliicli  at  each  menstrual  period,  or  at  every  second, 
third,  or  f oui^th  period,  a  distinct  membrane  is  shed  from  the  nterus  dur- 
ing the  flow  "which  is  accompanied  by  severe  dysmenorrhoea.  If  one 
accepts  the  desquamation  theory  of  Sir  John  Williams,  membranous 
dysmenorrhoea  is  easily  explained ;  and,  similarly,  if  the  hypothesis  of 
Engleiuann  be  correct  —  that  during  menstruation  a  proliferated  mucous 
membrane  is  shed  —  then  we  can  say  that  membranous  dysmenorrhoea 
is  merely  an  exaggeration  of  a  normal  process,  and  that  the  membrane 
is  discharged  in  mass  instead  of  in  minute  particles. 

This  curious  affection  was  formerly  supposed  to  be  inflammatory ;  and 
the  shed  membrane  was  compared  to  the  inflammatory  exudation  cast  off 
from  the  respiratory  passages  during  an  attack  of  croup.  But  for  many 
years  it  has  been  known  that  we  have  to  deal  not  with  an  inflammatory 
exudation,  but  with  an  exfoliation  of  the  mucous  membrane  of  the  uterus. 
This  resembles  the  early  decidua  in  every  respect  and,  like  it,  is  a  tri- 
angular-shaped sac  with  three  openings,  rough  and  irregular  on  the  outer 
surface,  smooth  on  the  interior.  Examined  microscopically,  the  membrane 
possesses  the  complex  structure  of  an  hypertrophied  endometrium,  and 
contains  follicles,  nucleated  cells,  and  blood-vessels.  Sometimes  the 
membranous  sac  is  cast  off  entire,  but  more  commonly  it  is  shed  in 
pieces.  Occasionally  only  the  superficial  layers  of  the  mucous  membrane 
are  cast  off ;  much  more  commonly  the  membrane  is  thick,  and  represents 
the  whole  thickness  of  the  hypertrophied  and  swollen  endometrium. 

Virchow  says  that,  on  examining  the  uterus  after  death  in  women  who 
have  died  while  suffering  from  dysmenorrhoea,  he  has  found  the  mucous 
membrane  in  process  of  separation.  Wylie  says  that  if  it  be  accepted 
that  a  cellular  disintegration  takes  place  during  normal  menstruation, 
it  is  possible  to  imagine  that  if  this  degeneration  take  place  in  the  deeper 
layers  of  the  mucous  membrane,  before  the  breaking  down  of  the  more 
superficial  layers,  these  latter  might  be  thrown  off  as  a  membrane. 

It  would  appear  that  the  membrane  expelled  belongs  to,  or  is  the 
product  of  the  former  menstrual  period.  If  normally  the  mucous 
membrane  is  thrown  off  during  the  latter  days  of  the  flow,  it  would  seem 
that  in  these  cases  of  membranous  dysmenorrhoea  the  exfoliation  is  post- 
poned; and  the  membrane  continues  to  grow  during  the  intermenstrual 
period. 

Hausmann  adopted  the  view  that  these  membranes  are  early 
abortions ;  but,  although  the  membrane  is  not  distinguishable  from 
decidua,  the  repeated  occurrence  and  the  absence  of  the  villi  of  the 
chorion  make  a  distinction  between  them,  as  a  rule,  comparatively  sure. 

SijiaptoiiLH. — The  condition  is  peculiar  to  married  women,  although 
minute  shreds  are  observed  in  single  women.  The  membrane  is  cast  off 
on  the  K(!(;ond  or  third  day  of  the  flow,  as  a  wliole,  or  at  any  rate  in 
tangible  [)ieces,  every  month,  or  every  second,  third,  or  fourth  month. 
The  discliarge  is  accompanied  by  severe  colicky  pains  which  are  sometimes 
of  a  most  violent  nature.  The  flow  may  be  excessive  or  normal  in  quantity ; 


DISORDERS   OF  MENSTRUATION  367 

but  it  frequently  presents  an  intermittence,  due  probably  to  the  plugging 
of  the  OS  internum  by  the  membrane.  The  patients  are  sterile,  and  this 
state  is  due  to  the  mucous  membrane  being  so  altered  pathologically  that 
it  does  not  form  a  suitable  nidus  for  the  ovum.  Membranous  dysmenor- 
rhoea  is  frequently  associated  with  other  uterine  disease,  such  as 
uterine  catarrh  or  displacements ;  but  these  alone  do  not  account  for 
its  existence. 

The  prognosis  is  uniformly  unfavourable,  as  in  most  well-marked  cases 
it  continues  during  the  menstrual  life  of  the  patient. 

Treatment.  — Any  existing  complication  should,  of  course,  be  removed : 
and  thereafter  the  dysmenorrhoea  is  best  treated  by  free  dilatation  of  the 
cervical  canal,  curettage  of  the  uterus,  and  the  application  of  strong 
escharotics  to  its  interior.  Intra-uterine  drainage,  too,  has  sometimes 
been  followed  by  fairly  satisfactory  results.  If  these  means  fail,  and  the 
patient's  suffering  continue,  the  alternative  of  removal  of  the  appendages, 
so  as  to  induce  premature  menopause,  would  have  to  be  considered. 

Internally  no  medicines  have  a  better  effect  than  the  continued  use 
of  arsenic,  iodide  of  potassium,  and  mercury. 

II.  Extra-uterine  Dysmenorrhoea.  —  The  extra-uterine  variety  of 
dysmenorrhoea  is  that  which  has  its  origin  in  some  abnormal  condition 
of  the  uterine  appendages.  It  is  commonly  called  '*  ovarian,"  but  iu 
many  cases  the  cause  of  the  pain  lies  in  the  Fallopian  tubes,  or  in  the 
pelvic  peritoneum  in  the  neighbourhood  of  the  ovary. 

This  form  of  dysmenorrhoea  is  associated  with  a  very  definite  set  of 
symptoms,  and  it  may  occur  either  in  the  single  or  married  woman:  it 
is  found,  however,  more  frequently  in  married  or  parous  women  than  in 
the  single,  for  reasons  we  shall  presently  see.  The  ovaries  and  tubes 
in  young  women  may  become  the  seat  of  inflammatory  changes,  as  the 
sequela  of  any  of  the  exanthemata,  or  as  an  after  result  of  influenza,  or, 
at  times,  as  the  consequence  of  a  direct  chill.  At  other  times,  again,  they 
may  become  thus  affected  \\\  young  women  by  an  inflammatory  process 
spreading  from  neighbouring  organs.  In  married  or  parous  women, 
while  these  influences  may  be  at  work  in  producing  a  salpingitis  or 
ovaritis,  or  a  combined  salpingo-ovaritis,  yet  in  these  there  are  other 
factors  more  prominently  at  work  ;  the  first  of  them  is  the  spreading  of 
sepsis  into  the  uterine  appendages  as  the  result  of  abortion  or  parturition. 

In  these  cases,  if  the  inflammatory  process  be  at  all  well  marked, 
and  more  especially  if,  as  is  generally  the  case,  it  affects  both  sides,  the 
usual  results  are  acquired  dysmenorrhoea  and  sterility.  Now  such  a 
condition  can  be  quite  well  recognised  clinically,  though  it  may  present 
different  features  in  various  cases.  For  example,  one  or  other  ovary  may 
be  simply  enlarged,  tender,  and  prolapsed  low  down  into  the  pouch  of 
Douglas ;  of  the  two  ovaries  the  left  suffers  most.  Again,  the  tube  may 
be  enlarged  and  thickened,  or  may  be  the  seat  of  one  of  the  grosser 
lesions,  such  as  hydro-,  pyo-,  or  hrematosalpinx ;  or  the  appendages  on 
one  or  both  sides  may  be  matted  together  by  perimetric  effusion  and 
deposit.     Further,  there  is  a  cause,  but  too  frequent,  both  in   single 


368  SYSTEM  OF  GYNECOLOGY 

and  married  women,  of  inflammatory  disease  of  the  uterine  appendages ; 
namely,  the  infection  from  gonorrhoea.  Yet  another  source  of  infection 
is,  unfortunately,  well  enough  known ;  a  salpingo-ovaritis  may  very  easily 
be  set  up  as  a  result  of  ill-managed  operative  interference  on  the  uterus 
itself,  by  the  improper  or  injudicious  use  of  instruments,  and  by  the 
disregard  of  antiseptic  precautions. 

It  must  be  obvious  that  no  such  condition  of  salpingo-ovaritis  can 
be  present  to  any  extent  without  implication  of  the  uterus  in  the 
inflammatory  change ;  hence  it  comes  that  under  these  conditions  a 
mixed  form  of  dysmenorrhoea  is  met  with :  the  symptoms  are  sufficiently 
definite,  however,  to  indicate  the  tubal  and  ovarian  origin  of  the  pain. 
It  is  no  part  of  my  present  duty  to  describe  the  symptoms  in  general  to 
which  tubo-ovarian  inflammation  gives  rise,  among  which  are  constant 
pelvic  pain,  menorrhagia,  pain  during  defsecation,  dyspareunia,  and, 
especially  dysmenorrhoea.  Now  this  dysmenorrhoea  manifests  itself  in  a 
characteristic  way.  It  is  essentially  premenstrual,  that  is  to  say,  the 
constant  pelvic  uneasiness  of  which  the  patient  complains  passes  into 
definite  suffering  and  pain  from  three  to  six  days  before  the  external 
manifestation  of  menstruation.  If  the  uterus  be  but  slightly  implicated 
the  patient  sometimes  gets  relief  on  the  onset  of  the  haemorrhage ;  but, 
on  the  other  hand,  if  the  endometritis  be  marked,  or  the  salpingo-ovaritis 
of  a  high  degree,  the  pain  will  probably  continue  all  through  the 
period.  This  pain  is  mainly  confined  to  the  region  of  one  or  other  ovary, 
and  is  often  so  severe  as  to  keep  the  patient  in  a  state  of  unrest  for 
days  before  menstruation  sets  in. 

The  reason  of  this  premenstrual  pain  is  that  the  tubes  and  ovaries, 
already  in  a  chronically  inflamed  state,  become  gradually  more  and  more 
congested  as  the  day  of  menstruation  approaches ;  thus  when  the  flow  is 
established  in  many  cases,  and  the  congestion  reduced,  a  corresponding 
relief  is  obtained ;  and  the  patient,  although  never  absolutely  free  from 
pain,  remains  comparatively  well  for  ten  days  or  a  fortnight  after  her 
period. 

The  prognosis  is  essentially  bad.  Perhaps,  next  to  membranous 
dysmenorrhoea,  this  variety  is  the  most  difficult  to  cure.  In  the  form 
affecting  young  girls  the  results  are  decidedly  more  satisfactory  than  in 
th(jse  women  in  whom  the  disease  is  directly  the  result  of  abortion, 
parturition,  or  gonorrhoea.  Further,  one  main  element  in  the  prognosis 
is  the  ability  of  the  patient  to  obtain  the  advantages  of  long  rest  and 
prolonged  treatment.  Yet  in  any  case,  so  far  as  the  cure  of  the 
dysmenorrhoea  is  concerned,  the  prognosis  must  always  be  very  guarded. 

In  this,  as  in  all  other  varieties  of  dysmenorrhoea,  there  are  two 
methods  of  treatmant  —  the  medical  and  the  surgical.  With  regard  to  the 
medical  treatment;  as  the  constant  cycle  of  changes,  througli  which 
the  uterus  and  its  appendages  are  montli  by  month  ])assing,  is  one  of 
the  most  important  factors  in  tlie  delay  of  euro,  it  is  clear  that  tlie 
patient  must  be  withdrawn  IVom  any  conditions  which  might  accentuate 
these  changes.     Hence  the  iirst  ])rovision  is  complete  rest  —  mental, 


DISORDERS   OF  MENSTRUATION  369 

physical,  and  sexual.  This  must  be  associated  with  those  remedies 
which  reduce  liyperaBmia  and  discuss  deposits.  First  and  foremost  comes 
systematic  hot  douching,  accompanied  by  the  introduction  of  ichthyol, 
either  as  a  pessary  or  as  a  dressing,  into  the  vagina.  I  know  of  no  drug 
which  has  a  more  powerful  local  effect,  and  I  am  confident  that  its  per- 
sistent use  has  saved  many  an  ovary  from  the  surgeon's  knife,  but  its  use 
must  be  persistent.  To  paint  the  roof  of  the  vagina  with  iodine  (half- 
and-half  tincture  and  liniment)  twice  a  week,  and  to  place  an  occasional 
blister  over  the  brim  of  the  pelvis,  will  facilitate  the  cure.  Internally 
liquor  hydrargyri  perchloridi,  with  iodide  of  potassium  and  saline 
purgatives,  will  be  found  beneficial. 

It  is  obvious  that  such  treatment  will  in  any  case  be  tedious,  and 
more  or  less  so  according  to  the  severity  of  the  inflammation :  thus  it 
must  be  evident  that  such  treatment  is  obtainable  only  by  the  compar- 
atively well  to  do ;  and  even  in  them,  when  the  condition  has  become 
chronic,  a  complete  cure  is  by  no  means  frequently  met  Avith.  In  these 
patients,  after  the  treatment  has  been  carried  out  at  home  for  some 
months,  a  course  of  baths  at  Woodhall  Spa  or  Eras  will  be  of  mucli 
value.  For  the  palliative  treatment  of  the  dysmenorrhoea  proper  most 
of  the  drugs  to  which  I  have  already  referred  will  give  temporary  relief. 
Yet  it  comes  about  that  under  three  possible  circumstances,  surgical 
treatment  has  in  many  cases  to  be  taken  into  consideration  :  these  cir- 
cumstances are  —  (a)  longstanding  and  intractable  dysmenorrhoea ;  (6) 
various  mental  and  nervous  phenomena,  said  to  be  associated  with  dys- 
menorrhoea; and  (c)  inflammatory  or  grosser  lesions  in  the  uterine 
appendages  associated  with  dysmenorrhoea  and  other  symptoms. 

I  think  there  are  few  cases,  if  any,  in  the  first  set  in  which  the  pro- 
cedure can  be  recommended,  as  most  kinds  of  uterine  and  extra-uterine 
dysmenorrhoea  can  be  palliated  without  recourse  to  oophorectomy.  It 
is  only  justifiable  when  the  dysmenorrhoea  is  associated  with  the  other 
well-marked  symptoms  to  which  tubal  and  ovarian  disease  gives  rise. 
The  operation,  as  a  rule,  is  an  easy  one,  and  is  undertaken  too  often 
on  insufficient  grounds.  Further,  even  after  oophorectomy  a  cure  is 
by  no  means  uniformly  obtained,  because,  as  I  have  already  said,  the 
menopause  is  not  invariably  induced ;  the  patient  often  menstruates 
regularly,  and  sometimes  even  with  pain :  moreover,  though  menstru- 
ation may  cease,  periodic  monthly  pain  may  recur  for  a  year  or  two 
at  least.  In  all  cases  removal  of  the  ovaries  should  not  be  adopted 
until  all  other  means  of  treatment  have  failed ;  and  then  only  as  a  last 
resource. 

Intermenstrual  Pain.  —  There  is  a  form  of  dysmenorrhoea,  if  so  it 

may  be  called,  which  occurs,  not  at  the  time  of  the  external  manifesta- 
tion of  menstruation,  but  at  mid-term ;  to  this  condition  the  Germans 
have  given  the  more  appropriate  name  of  "  Mittelschmevz"  ;  the  Fronch, 
less  felicitously,  the  name  of  "  Dysmenorrhee  intermenstruelle.- '  Wliat- 
ever  name  may  be  applied  to  it  —  and  certainly  intermenstrual  dysmen- 

2b 


370  SYSTEM   OF  GYX.-ECOLOGY 

orrlioea  is  not  a  suitable  one  —  the  condition  in  wliieh  an  attack  of 
dysmenorrhoea  proper  is  simulated,  without,  necessarily,  any  external 
lisemorrliage,  -is  well  ascertained.  It  does  not  at  all  resemble  the  pre- 
menstrual pain,  or  the  continued  pain  associated  with  inflamed  or 
diseased  ovaries;  but  it  is  a  condition  which  occurs  definitely  each 
month,  at  a  definite  period,  and  for  a  definite  number  of  days. 

So  far  as  I  am  aware,  the  condition  was  first  of  all  described  by  Sir 
William  Priestley  many  years  ago ;  it  has  been  also  discussed  by  Fas- 
bender  and  Sorel. 

The  four  cases  recorded  by  Priestley  had  the  following  as  their  prom- 
inent features :  pain,  paroxysmal,  in  the  region  of  the  ovary,  occurring 
during  the  intermenstrual  period ;  in  some  cases  continuing  up  to  the 
commencement  of  the  flow,  in  others  stopping  before  it ;  the  ordinary 
flow  is  usually  scanty,  but  regular,  and  with  no  pain.  In  two  cases  a 
tumour  was  felt,  on  bimanual  examination,  in  the  region  of  the  broad 
ligament,  adherent  to  the  uterus,  elastic  to  touch.  In  the  other  two 
cases  only  thickening  in  the  region  of  the  broad  ligament  was  found. 

Sorel  records  a  case  presenting  symptoms  similar  to  those  mentioned 
above,  in  which  the  condition  had  existed  for  a  great  number  of  years ; 
indeed,  it  had  been  observed  during  a  period  in  Avhich  147  menstrual 
epochs  had  occurred.  The  chief  conclusion  arrived  at  by  this  author 
was  that  the  occurrence  of  the  intermenstrual  pain  bore  a  more  defi- 
nite relation  to  the  commencement  of  the  period  which  followed  it  than 
to  the  period  which  went  before ;  as  fourteen  days  always  elapsed  be- 
tween the  occurrence  of  the  pain  and  the  commencement  of  the  men- 
strual period. 

One  of  the  most  important  contributions  to  the  very  scanty  literature 
of  this  subject  is  an  article  by  Heinrich  Fasbender,  in  which  he  expresses 
his  view  of  the  etiology  of  Mittelschmerz  as  follows:  —  Accepting  Pfl ti- 
ger's theory  of  menstruation,  we  have  in  some  cases  a  premature  sum- 
mation of  nervous  stimuli  in  the  ovary,  with  the  occurrence  of  ovulation, 
caused  either  by  a  delicately  organised  and  excitable  state  of  the  whole 
nervous  system,  or  of  the  nerves  of  the  ovary ;  the  latter  state  produced 
by  a  pathological  condition  of  the  ovary.  This  abnormal  irritability, 
leading  to  dehiscence  of  a  follicle  some  fourteen  days  before  the  proper 
menstrual  period,  produces  the  congestive  condition  of  the  pelvic  organs 
found  in  cases  examined  at  such  a  time. 

"  Mittelschmerz,"  with  a  slight  flow  of  blood,  is  also  described  by 
Herr  Benicke  as  occurring  in  a  case  where  there  existed  a  conical  cervix 
with  pin  hole  os,  anteflexion  of  the  uterus,  and  retraction  of  the  utero- 
sacral  ligament. 

From  the  above  notes  along  with  my  own  recorded  cases  (8),  the  con- 
dition, it  seems  to  me,  can  be  well  c(jnsider(;d  under  three  different  man- 
ifestations :  (a)  A  group  of  cases  in  which  there  is  no  external  discharge 
at  all.  (h)  Those  cases  where  the  pain  is  associated  with  an  escape  of 
blood,  (c)  Those  in  which,  as  in  two  of  my  cases  and  some  of  the  others, 
the  intermenstrual  pain  is  associated  with  a  clear  discharge. 


DISORDERS    OF  MENSTRUATION  371 

It  would  be  absurd  to  dogmatise  upon  the  causes  of  this  condition  ;  or 
to  lay  down  any  hard  and  fast  rules  as  to  the  pathological  conditions 
necessary  to  its  production  :  but  it  seems  to  me  that  the  above  classifica- 
tion gives  a  fair  insight  into  the  different  states  that  may  lead  to  the 
})roduction  of  this  somewhat  unusual  symptom,  (a)  Of  those  cases  where 
no  external  manifestation  accompanies  the  occurrence  of  "  Mittelschraerz," 
the  explanation  is  probably  to  be  found  in  the  fact  that  ovulation  and 
menstruation  do  not  in  these  cases  occur  simultaneously ;  and  that,  in 
addition,  owing  to  thickening  of  the  capsule  of  the  ovary  or  some  such 
cause,  dehiscence  of  the  follicle  is  attended  with  pain.  (6)  Those 
associated  with  escape  of  blood.  In  all  of  these  it  will  be  observed 
that  more  or  less  endometritis,  anteflexion,  and  enlargement  of  the 
uterus  were  present ;  and,  so  far  as  I  am  able  to  judge,  these  were  simply 
cases  in  which  a  slight  intermenstrual  flow,  due  to  endometritis,  was 
accompanied  by  well-marked  pain  during  the  passage  of  clots.  Such 
a  condition  is  well  recognised  and  common,  and  scarcely,  I  think, 
should  come  under  the  category  of  '' Mittelschmerz "  at  all.  Still, 
it  adequately  enough  describes  a  set  of  cases  to  which  the  Germans 
especially  have  drawn  attention,  (c)  Lastly,  in  those  cases  in  which  a 
leucorrhoeal  discharge  occurs  with  the  "  Mittelschmerz,"  and  in  which, 
just  before  the  usual  date  of  the  occurrence  of  the  pain,  a  swollen  and 
fluctuating  condition  of  the  tubes  was  in  some  cases  made  out,  I  think 
there  can  be  no  question  that  the  cause  of  the  intermenstrual  pain 
was  to  be  found  in  hydrops  Fallopii,  reaching  its  full  development  at 
mid-term. 

I  am  well  aware  that  much  doubt  is  now  thrown  upon  the  possibility 
of  what  is  called  "  intermitting  hydrosalpinx,"  or  "  hydrops  tubae  pro- 
fluens  "  —  the  occasional  sudden  escape  of  fluid  through  a  temporarily 
patent  uterine  end,  with  disappearance  or  diminution  in  size  of  the 
tubal  dilatation.  According  to  some  authors,  it  is  much  more  likely 
that  these  discharges  pass  away,  not  by  the  cervix,  but  by  a  vaginal 
fistula  communicating  with  the  cyst.  Either  explanation  is  compatible 
with  this  view  of  mine. 

In  the  cases  I  have  recorded  (8),  in  which  a  removal  of  the  tubes  and 
ovaries  brought  about  a  cessation  of  the  "  Mittelschmerz,"  it  may  be  urged 
that  the  pain  had  been  ovarian,  and  that  its  cessation  Avas  due  not  to 
the  removal  of  the  hydrosalpinx,  but  to  the  removal  of  the  ovary. 
Here  I  would  remark  that  colicky  pain  in  the  tubes  does  occur  in  such  a 
condition,  contractions  of  the  sac  forcing  the  fluid  through  a  uterine 
orifice  onlj^  partially  closed;  and  also  that  pain  may  be  due  to  dis- 
charge of  uterine  contents,  the  result  of  reflex  contraction  of  a  neces- 
sarily congested  uterus.  Thus  it  is  more  than  likely  that  the  pain 
is  really  tubal. 

J.   Halliday    Croom. 


372  SVSTEA/  OF  GYNECOLOGY 


REFERENCES 

1.  Allbutt,  T.  Clifford.  Med.-Chir.  Trans.  1865-6,  xlix.  161-164.— 2.  Beau,  De. 
Amer.  Med.  Journ.  vol.  xi.  —  3.  Benicke.  See  Fasbeuder,  No.  2U. — 1.  Bouchart.  Gazette 
des  i/o^j(7((Ui-,  November  1876. — 5.  Campbell.  JVoj-thei-n  Journal  of  Medicine,  1845. 
— 6.  Champneys.  "  Ou  Painful  Menstruation,"  Harveian  Lectures,  1890. — 7.  Cook, 
W.  Med.-Chir.  Trans.  1813.  — 8.  Croom,  H.  Edin.  Med.  Journ.  1896,  vol.  i.— 9. 
Czempix.  Zeits.  f.  Geb.  u)td  (?2//i.  Bd.  xiii.  Heft  2.  — 10.  Englemann.  Anier.  Journ. 
Obstet.  vol.  viii.  i875-6,  p.  30.  — 11.  Fasbender.  Zeits.  fur  Geburtshiilfe  u.  Frauen- 
krankheiten,  1876.  — 12.  Fritsch.  Die  Lageveriinderungen  U7id  die  Entzilndungen  der 
Gebiirnni'ter.  Stuttgart,  1885. —  13.  Harding,  C.  Lancet,  1879.  — 14.  H-\rle,  C.  E. 
Brit.  Med.  Journ.  June  1880.  — 15.  Harris,  Amer.  Journ.  of  Obstetrics,  vol.  iii.  p.  616. — 
16.  Hausmann.  Berlin  Beit,  zur  Geb.  u.  Gyn.  1872,  S.  155.  — 17.  Kammerer.  Trans.  New 
York  Acad,  of  Medicine,  1866-9,  iii.  pt.  7,  pp.  1-10.-18.  Kehrer.  Zur  Sterilitiitsleh^'e 
Beitr.  z.  klin.  Gebdrtsch.  1879-80,  ii.  76-139.-19.  Jackson.  "On  some  Points 
connected  with  the  Treatment  of  Sterility,"  Tr.  Amer.  Gyn.  Soc.  iii.  347-362,  1879.— 
20.  Jones.  Ame?:  Journ.  Obstet.  1887,  vol.  xx.  p.  92.-21.  Lucas,  C.  Clin.  Soc. 
Trans.  1888.-22.  LusK.  Amer.  Journ.  Obstet.  1891.-23.  Morgagni.  De  Sedibxis 
et  Causis  Morborum,  2  vols.  Venet.  1762.  —  24.  Pozzi.  Traits  de  gynecologic  clinique 
et  op^ratoire.  —  25.  Priestley,  Sir  W.  B7'it.  Med.  Journ.  1872,  ii.  p.  431.  —  26. 
Simpson,  Sir  J.  Med.  Times  and  Gazette,  18.59,  i.  p.  179.-27.  Sims.  The  Lancet,  1865, 
vol.  ii.  p.  42.-28.  Smart,  R.  B.  Med.-Chir.  Tra7is.  1858.— 29.  Sorel.  A7-chives 
de  Tocologie  des  Maladies  des  Fe77i7nes,  1887.  —  30.  Virchow.  Gesa77i.  Abha7idlunge7i, 
1855,  S.  774.  —  31.  Williams,  Sir  J.  Obstet.  Journ.  of  Great  B7-itai7i  a7id  Ii-ela/id, 
1875,  vols.  ii.  and  iii.  1877.  — 32.  Wright.  B7'it.  Med.  Journ.  1893.-33.  Wyhe.  A 
System  of  Gy7isecology  by  A7nerican  Authors,  1887. 

J.  H.  C. 


DISEASES  OF   THE  EXTERNAL   GENITAL   ORGANS 

HvPERiEMiA.  —  Active  or  arterial  hyperaemia  is  usually  the  first  stage  of 
inflammation.  It  occurs  in  infants  from  want  of  cleanliness,  and  in  older 
children  and  adults  from  mechanical  or  chemica,l  irritation ;  such  as 
masturbation,  scalds,  and  strong  chemical  applications.  An  important 
cause,  from  a  medico-legal  point  of  view,  is  the  rape  of  young  children, 
which  is  usually  followed  by  much  congestion  and  swelling,  but  seldom 
goes  on  to  inflammation. 

Passive  congestion  or  venous  hyperaemia  results  from  obstruction 
to  the  venous  circidation  in  liver,  heart,  or  lungs;  also  in  pregnancy. 
Prolonged  venous  congestion  may  lead  to  permanent  varicosity  of  the 
veins.  Passive  congestion  may  cause  oedema  of  the  labia  majora,  both 
laV>ia  becoming  swollen,  white,  shining,  and  translucent.  In  inflamma- 
tory oedema  the  swelling  is  usually  unilateral,  and  involves  the  lesser, 
as  well  as  the  greater  labium. 

TrfiatmpM.  —  The  treatment  of  passive  congestion  should  be  directed 
to  the  cause  of  it.  In  pregnancy  it  may  often  be  relieved  by  a  suitable 
abdominal  belt,  and  by  the  recumbent  posture.  Should  the  skin  break 
special  care  is  necessary  to  prevent  septic  infection;  such  cases  are 
especially  liajjle  to  erysipelatous  inflammation. 


DISEASES   OF  THE   EXTERNAL    GENITAL    ORGANS  373 

Inflammations.  —  The  characteristics  of  inflammation  of  the  vulva 
vary,  not  only  with  the  irritant  which  causes  it  and  the  condition  of  the 
affected  parts,  but  also  with  their  anatomical  structure ;  so  that  in- 
flammatory affections  can  be  divided  into  those  which  affect  the  mucous 
membrane,  the  skin,  and  the  glandular  structures  respectively.  In 
practice,  however,  it  will  be  found  that  all  these  structures  are  affected 
simultaneously  in  varying  degree.  For  clinical  purposes  we  may  divide 
vulvitis  into  the  following  varieties :  i.  Traumatic ;  ii.  Catarrhal ; 
iii.  Dermal  (dermatitis,  eczematous,  herpetic,  pruriginous) ;  iv.  Ulcera- 
tive; V.  Septic;  vi.  Diphtheritic;  and  vii.  Erysipelatous. 

i.  Traumatic  vulvitis  resulting  from  burns,  scalds,  powerful  caustics, 
or  injuries,  usually  heals  spontaneously. 

ii.  Catarrhal  vulvitis  may  be  acute  or  chronic.  It  is  common  at 
all  periods  of  life,  and  is  generally  due  to  some  constant  source  of 
irritation,  or  to  the  introduction  of  septic  material  from  without;  by 
want  of  cleanliness,  contact  of  dirty  fingers  as  in  scratching,  coitus, 
masturbation,  gynaecological  manipulations,  dirty  sponges,  soiled  linen, 
septic  vaginal  discharges  such  as  putrid  lochia  and  menstrual  flow,  and 
those  resulting  from  neglected  tampons,  sloughing  cancer  or  myoma; 
or  by  contact  with  ammoniacal  or  saccharine  urine  and  faeces  in  cases  of 
vesico-vaginal  and  recto-vaginal  fistula.  In  infants  the  causes  are  want 
of  cleanliness  and  constant  contact  with  decomposing  urine  and  faeces  ; 
in  older  children,  oxyurides  wandering  into  the  vagina  from  the  rectum 
lead  to  scratching  and  rubbing ;  and  the  wounds  thus  caused  become 
infected  and  inflamed.  At  all  ages  gonorrhoea  is  a  frequent  and  im- 
portant cause,  and  the  epidemics  of  vulvo-vaginitis  which  occur  in 
schools  are  probably  attributable  to  it. 

Purulent  vulvitis  is  generally  gonorrhoeal  both  in  children  and 
adults.  The  importance  of  gonorrhoea  in  women  was  pointed  out  nearly 
a  quarter  of  a  century  ago  by  Noggerath,  but  has  only  recently  received 
the  attention  which  it  deserves.  According  to  Sanger,  12  per  cent  of 
all  the  women  who  consult  a  gynaecologist  suffer  from  gonorrhoea,  and 
considerably  more  than  one-third  of  sterile  marriages  are  due  to  this 
disease.  Acquired  sterility  after  the  birth  of  one  child  Sanger  believes 
to  be  due,  as  a  rule,  to  gonorrhoea.  But  there  may  be  purulent 
vulvitis  which  is  not  gonorrhoeal ;  it  is  met  with  most  frequently  in 
poorly  nourished  lymphatic  children,  and  in  obese  women. 

Signfi  and  Si/mjitoms.  —  In  acute  Ami vitis  there  is  sharp  local  pain, 
increased  by  movement  and  micturition ;  the  inflamed  structures 
become  rod  and  swollen,  and  there  is  a  mucous,  muco-purulent,  or  puru- 
lent discharge.  The  glands  of  Bartholin  may  be  involved,  leading  to 
abscess.  In  gonorrhoeal  vulvitis  the  symptoms  are  especially  acute.  In 
chronic  vulvitis  the  signs  are  less  pronounced;  there  is  less  swelling 
and  redness,  often  excoriation  with  hypertrophied  papillae.  The  glan- 
dular structures  about  the  vulva  sometimes  participate  in  the  inflamma- 
tion and  form  small  projections,  pustules,  or  boils ;  to  these  the  term 
follicular  vulvitis  has  been  applied.     The  glands  of  Bartholin  nuiy  also 


374  SYSTEAf   OF  GYNMCOLOGY 

be  implicated;  in  which  case  they  are  indurated,  and  exude  a  little 
milky  or  greenish  pus.  Sir  Wm.  Priestley  described  a  form  of  vuhdtis 
under  the  name  of  chronic  papillary  inflammation  of  the  vulva ;  and 
Matthews  Duncan  a  somewhat  similar  condition,  of  a  very  obstinate 
nature,  which  he  considered  to  be  closely  allied  to  lupus.  Trachoma 
pudendorum  is  a  name  applied  by  Tarnovvsky  to  a  condition  found  in 
prostitutes  as  a  result  of  gonorrhoea;  it  is  characterised  by  grayish  or 
yellowish  nodules  about  the  size  of  a  pin's  head. 

Diagnosis. — The  signs  and  symptoms  are  usually  clear  enough  to 
render  the  diagnosis  of  vulvitis  easy ;  but  it  is  often  difficult  to  distin- 
guish one  variety  from  the  other.  It  is  especially  important,  but  often 
impossible  to  determine  Avhether  the  inflammation  present  be  of  a 
gonorrhoeal  nature  or  not.  The  history  of  the  case  is  generally  want- 
ing or  misleading ;  but  the  following  features  may  be  looked  upon  as 
important :  —  a  purulent  discharge  in  the  absence  of  ulceration,  erosion, 
or  malignant  disease  associated  with  inflammation  of  the  urethra  and 
glands  of  Bartholin ;  a  well-defined  reddish  margin  around  the  urethral 
orifice,  and  two  bright  red  spots  marking  the  orifices  of  the  ducts  of 
Bartholin's  glands  (macula  gonorrhoica,  considered  by  Sanger  as  espe- 
cially important) ;  warty  condylomata  complicated  with  granular 
vaginitis ;  salpingo-perimetritis  ;  sudden  development  of  inflammatory 
disease  of  the  genital  organs  in  a  newly  married  woman,  which  injures 
her  health  to  a  degree  out  of  all  proportion  to  the  local  condition ; 
habitual  abortion ;  sterility  acquired  after  the  birth  of  one  child ;  oph- 
thalmia neonatorum,  and  especially  the  detection  of  the  gonococcus. 

Prognosis.  —  In  simple  vulvitis,  provided  the  cause  can  be  removed, 
the  prognosis  is  good.  Gonorrhoea  in  women  is  always  a  serious  dis- 
ease, much  more  so  than  in  men ;  but  Veit  believes  that  the  inflamma- 
tion resulting  from  a  single  inoculation  will  always  heal  spontaneously, 
an  opinion  he  has  founded  upon  clinical  observations  and  experiment. 
He  has  never  met  with  a  case  of  inflammation  of  the  uterine  append- 
ages resulting  from  a  single  infection ;  but  repeated  inoculations  render 
the  prognosis  a  much  more  serious  matter.  In  general  terms  it  may  be 
said  that  so  long  as  the  disease  has  not  advanced  above  the  os  internum 
the  prognosis  is  relatively  good,  but  once  the  tubes  and  peritoneum 
become  inflamed  a  cure  is  very  improbable.  Even  when  the  disease  is 
limited  to  the  vulva  and  vagina,  especially  if  it  involve  the  glands  of 
i>artholin,  it  may  run  a  chronic  course;  it  often  remains  latent  for 
years,  and  suddenly  recurs  without  fresh  infection.  An  ingenious 
theory  to  account  for  this  phenomenon  has  been  suggested  by  Luther 
of  Magdeburg.  It  is  well  known  that  the  disease  usually  spreads  by 
the  gonococci  invading  and  destroying  the  cells,  and  the  microbes  thus 
set  free  invade  other  cells.  According  to  Luther's  theory,  the  gonococci 
in  the  course  of  time  become  attenuated,  and  failing  to  destroy  the  cells, 
remain  latent  in  tliem  ;  but  should  a  tissue  thus  invaded  become  subject 
to  traumatic  or  other  injury,  tlie  microbes  again  l)ecome  virulent  and, 
invading  other  cells,  rekindle  the  original  disease.  He  thinks  variation 
in  virulence  would  be  a  better  term  than  latency. 


DISEASES  OF  THE  EXTERNAL    GENITAL    ORGANS  375 

Treatment.  —  The  prophylaxis  of  vulvitis  consists  in  scrupulous 
cleanliness.  In  schools  and  institutions  it  is  of  great  importance  that 
each  person  should  have  her  own  basin  and  towel.  Sponges  should 
as  far  as  possible  be  avoided,  and  certainly  they  should  not  be  used  in 
common.  A  man  suffering  from  gonorrhoea  should  be  cautioned  as  to 
the  dangers  likely  to  follow  a  marriage  contracted  before  the  disease 
is  cured. 

In  acute  vulvitis  the  patient  should  be  confined  to  bed;  her  diet 
should  be  of  a  light,  unstimulating  character;  her  bowels  should  be  re- 
lieved by  a  mild  aperient,  and  she  should  sit  from  half  to  one  hour  in  a 
warm  hip  bath  to  which  has  been  added  carbonate  of  soda,  permanganate 
of  potash  or  bran ;  after  this  a  compress  wet  with  liquor  plumbi 
subacetatis  dilutus  (Goulard's  lotion),  solution  of  boric  acid  (^-  to  2  per 
cent),  or  salicylic  acid  (1  in  6000)  should  be  applied  and  frequently 
renewed.  The  compress  may  be  either  cold  or  hot  as  the  patient  may 
prefer.  A  similar  line  of  treatment  is  applicable  in  some  chronic  cases, 
but  astringent  and  antiseptic  applications  will  also  be  required.  Solutions 
containing  acetate  of  lead  and  opium,  tannin,  carbolic  acid  (1  in  40), 
sulphate  of  copper  (1  per  cent),  corrosive  sublimate  (1  in  3000), 
answer  this  purpose.  In  chronic  cases,  and  particularly  in  the  intertrigo 
of  fat  women,  dusting  powders  will  be  found  of  advantage,  as  for  example : 
Acidi  borici,  Zinci  oxidi,  aa  3ij. ;  Pulv.  amyli,  3iv. ;  Pulv.  rad.  iridis 
florentinae,  5j- 

Ointments  are  less  popular  now  than  they  were  formerly ;  still  they 
are  indispensable  in  some  cases,  especially  where  the  surface  has  to  be 
protected  from  irritating  discharges,  as  in  cancer,  fistula,  and  the  like. 
A  very  valuable  ointment  in  such  cases  is  the  oxide  of  zinc  ointment  of 
the  Pharmacopoeia  to  which  5  per  cent  of  carbolic  acid  has  been  added ; 
or,  if  there  be  much  local  irritation,  thymol  (2  per  cent),  or  cocaine 
(10  per  cent). 

In  follicular  vulvitis  the  pustules  should  be  opened,  and  the  parts 
fomented  with  an  antiseptic  compress. 

In  acute  inflammation  of  Bartholin's  glands  a  warm  sublimate  compress 
should  be  constantly  applied ;  and  as  soon  as  the  abscess  shows  any  tendency 
to  point,  it  should  be  freely  opened,  well  washed  out  with  an  antiseptic 
solution  (lysol  or  creolin),  and  the  cavity  packed  with  moist  iodoform 
gauze.  In  chronic  cases  a  similar  course  may  be  followed ;  but  total 
extirpation  of  the  gland  is  the  most  satisfactory  means  of  cure.  In 
gonorrhoeal  vulvitis  nitrate  of  silver  has  a  great  reputation ;  but  it  is 
probably  inferior  to  some  antiseptics  already  mentioned,  and  according  to 
Schaeffer  it  is  decomposed  and  rendered  useless  by  albumin  and  chloride 
of  sodium ;  he  proposes  as  a  substitute  for  it  argentamin  (diamine- 
silver-phosphate).  In  the  hope  of  aborting  the  disease  very  strong 
caustic  solutions  have  been  recommended  by  some  authorities,  but  this 
hope  is  illusory  owing  to  the  anatomical  conditions  of  the  parts  and  the 
biological  peculiarities  of  the  gonococci.  A  milder  and  more  prolonged 
course  of  treatment  is  more  satisfactory ;  and  it  must  not  be  forgotten 


376  SYSTEM   OF  GYNECOLOGY 

that  ^iilvitis  is  frequently  associated  with  vaginitis,  the  treatment  of 
which  ^houkl  not  be  overlooked.  After  bathing  or  douching,  the  labia 
should  be  kept  apart  by  a  tampon  soaked  in  iodine  and  glycerine.  In 
very  chronic  cases  benefit  has  resulted  from  the  use  of  chloride  of  zinc, 
ichthyol,  and  galvanism. 

iii.  Dermal  Vulvitis.  —  Simple  dermatitis  or  intertrigo  is  generally 
met  with  in  fat  women,  and  begins  in  the  groove  between  the  labia 
majora  and  the  thighs.  The  sweat  and  sebaceous  matter  collected  in 
this  groove,  submitted  to  heat  and  moisture,  decompose,  become  exceed- 
ingly irritating,  and  cause  inflammation  or  scalding. 

The  inflamed  parts  should  be  thoroughly  cleansed  with  warm  water 
and  some  non-irritating  soap,  or  with  a  soda  solution,  and  then  powdered 
with  boric  acid  or  iodoform.  Or  the  following  lotion  may  be  dabbed 
on:  Calamina3  prep.  5ss.,  Zinci  oxidi,  3  ij.,  Glycerini,  3j.,  Aq.  rosse,  ad 
Sviij. 

Eczematous  Vulvitis.  —  Eczema  may  be  acute  or  chronic,  but  the  latter 
is  more  common.  In  acute  eczema  the  patient  experiences  a  burning 
sensation  in  the  labia  majora;  this  is  followed  by  redness,  swelling,  and 
the  eruption  of  little  vesicles  about  as  large  as  a  pin's  head.  These  are 
often  overlooked,  and  are  best  seen  by  a  side  light.  When  they  burst 
they  leave  a  moist,  excoriated  surface  which  rapidly  becomes  covered  with 
crusts.  The  eruption  is  attended  with  a  certain  amount  of  fever  and 
gastric  disturbance. 

The  chronic  form  generally  appears  as  eczema  rubrum ;  it  is  seldom 
limited  to  the  labia  majora,  but  rapidly  involves  the  neighbouring  skin 
and  the  mucous  membrane  of  the  vagina.  It  frequently  occurs  in  gouty 
and  lymphatic  patients,  and  in  association  with  diabetes.  The  prognosis 
is  usually  good,  but  in  some  cases  the  disease  is  exceedingly  chronic. 

In  the  acute  stage  cold  or  warm  compresses  and  subacetate  of 
lead  lotion  are  generally  all  that  is  needed.  Where  crusts  have  formed 
oily  applications  are  necessary,  and  are  generally  used  in  the  form  of 
ointments. 

When  the  discharge  is  profuse  and  watery  the  surface  should  be 
powdered.  In  more  chronic  cases  Hebra's  unguentum  diachylum,  white 
precipitate  (jintment,  or — IJ  Acidi  borioi  3j.,  Plumbi  acet.  gr.  x., 
jjismiitlii  subnitr.  3  ij.,  Vaseliui  ad  5j-;  M.  ft.;  Ung.  Or  again  —  Pulv. 
amyli,  iiismiithi  carb.  ila  3  j.,  Cromoris  alb.  ad  §  j.;  M.  ft.;  Ung.  In  very 
chronic  cases  sapoviridis  and  tarry  preparations  may  be  used;  the  last- 
mentioned,  however,  with  caution. 

Herpes  vuIvk  is  characterised  by  the  appeara,nce  of  little  vesicles  in 
groups.  It  occurs  most  frequently  in  fat  women  at  the  commencement 
of  menstruation;  pregnancy  also  disposes  to  it.  The  eruption  is 
generally  preceded  by  a  l)urTiing  s(;nsation,  the  vesicles  disa])pearing  in 
from  seven  to  eight  days.  These  two  affections  are  very  liable  to  be  con- 
founded with  one  another:  eczema,  however,  has  a  tendency  to  spread 
at  the  edges  ;  herpes  appears  in  successive  crops.  In  eczema,  too,  the 
skin  is  more  or  less  involved  and  swollen ;  this  is  not  the  case  in  herpes. 


DISEASES    OF   THE   EXTERNAL    GENITAL    ORGANS  377 

Great  care  must  be  taken,  however,  not  to  confound  either  with  syphilitic, 
eruptions. 

Frariijo. — This  affection,  which  causes  very  distressing  itching,  is 
characterised  by  the  appearance  of  a  papular  eruption.  The  little 
papules  are  of  the  same  colour  as  the  skin,  and,  according  to  Klebs,  are 
due  to  dilatation  of  the  lymphatics  in  the  hypertrophied  papillae,  causing 
irritation  of  the  terminal  filaments  of  the  nerves  of  the  skin. 

The  diagnosis  is  more  easily  made  by  the  touch  than  by  sight,  —  a 
rough,  goose-skin  sensation  is  conveyed  to  the  examining  linger.  The 
disease,  which  is  of  a  very  obstinate  and  intractable  nature,  is  happily 
rare  in  these  countries. 

The  following  formulae  are  useful :  —  ^  Menthol,  3  ij.,  01.  olivae  3  iv., 
Chlorof.  3j.,  Lanolini  5ij.;  M.  ft.;  Ung.  A  cone  of  ol.  theobromge 
impregnated  with  cocaine,  2  per  cent  (Porritt).  ^  Ac.  salicyl.  3ss., 
Creasoti  ^,  xl.,  Glycerini  amyli  Siij-,  Lanolini,  3j.  ;  M.  ft.;  Ung. 

iv.  Ulcerative  vulvitis,  or  aphthous  vulvitis,  occurs  in  young  chil- 
dren from  two  to  five  years  of  age,  generally  after  the  exanthemata. 
Little  circumscribed  spots  appear  upon  the  mucous  membrane,  some- 
times ulcerate,  and  occasionally  become  gangrenous.  This  affection 
has  been  confounded  with  noma  pudendi ;  but  in  this  latter  disease 
gangrene  is  an  essential  characteristic,  not  an  accidental  sequela.  The 
child's  general  health  should  be  attended  to,  and  the  sj^ots  dusted  Avith 
some  mild  antiseptic  powder. 

V.  Septic  vulvitis  is  most  frequently  met  with  in  child-bed  in  the 
form  of  a  puerperal  ulcer ;  the  symptoms  which  accompany  this  ulcer 
are  fever  and  smarting  on  passing  water.  One  labium  is  usuallj- oedema- 
tous,  and  when  examined  upon  the  inner  surface,  a  fissure  or  ulcer  can  be 
discovered  having  a  white  base,  a  red  and  inflamed  margin,  and  a  thin, 
irritating  discharge  which  excoriates  the  surface  of  the  skin  over  which 
it  flows.  Formerly  these  ulcers  Avere  treated  very  actively,  and 
cauterised  Avith  strong  acids  or  the  actual  cautery  ;  but  such  violent 
measures  are  unnecessary :  healing  usually  goes  on  rapidly  Avhen  the 
affected  part  is  kept  clean  and  poAvdered  Avith  iodoform.  If  the  poison 
be  of  a  more  virulent  nature  gangrene  may  extend  more  Avidely,  and 
leave  deep  ulcers  which,  if  the  patient  recover,  may  lead  to  stenosis  of 
the  vulva. 

Noma  I'iudendi  is  a  name  applied  to  gangrene  of  the  vulva  occurring 
in  young  children,  especially  after  the  exanthemata,  and  resembling 
noma  of  the  face  Avhich  occurs  under  similar  circumstances.  This  disease 
is  due  to  septic  inflammation.  It  commences  Avith  burning  local  pain 
and  fever ;  the  tissues  swell,  becoming  dusky  red,  broAvn,  gray,  or  black  ; 
bullae  form  upon  the  surface  and  burst,  discharging  a  thin,  ichorous 
serum,  and  a  dark  slough  is  exposed.  The  disease  is  generally  fatal ; 
but  should  the  patient  recover,  there  will  be  marked  deformity  from 
cicatricial  contraction. 

The  treatment  must  be  general  as  Avell  as  local.  Alcohol  should 
be  given  in  large  quantities,  together  Avith  easily  assimilable  nourish- 


378  SYSTEM  OF  GYNECOLOGY 

ruent.  Locally  the  diseased  tissues  are  to  be  destroyed  -vrith  the  actual 
cautery  or  f umiug  nitric  acid ;  the  former  is  preferable.  Some  prefer 
excision  -n-ith  careful  disinfection  of  the  raw  surfaces,  the  wound  being 
closed  by  suture. 

vi.  Diphtheritic  and  dysenteric  vulvitis  are  complications  of  the  two 
diseases  respectively  concerned. 

vii.  Erysipelas  vulvae  occurs  in  young  and  neglected  children.  In 
adults  it  assumes  a  more  chronic  form,  and  has  a  tendency  to  recur  at 
each  menstrual  period,  disappearing  in  the  intervals.  There  is  redness  of 
the  skin  attended  by  a  burning  sensation,  pain  in  the  parts,  and  fever. 
The  disease  often  remains  latent  during  the  intervals  between  the  attacks, 
and  its  recurrence  is  due  to  an  alteration  in  the  nutrition  of  the  parts  at 
the  menstrual  periods. 

The  treatment  consists  in  dusting  with  powders  containing  boric  or 
salicylic  acid,  painting  with  nitrate  of  silver,  the  application  of  com- 
presses of  carbolic  acid  or  corrosive  sublimate.  Hypodermic  injection 
of  a  two  per  cent  solution  of  carbolic  acid,  first  recommended  by  Huter, 
has  been  used  with  benefit.  Benefit  has  also  been  derived  from  rubbing 
turpentine  into  the  skin. 

viii.  Pruritus  vulvae  is  the  term  applied  to  a  chronic  and  very  distressing 
condition  which  results  from  a  variety  of  causes.  It  is  doubtful  whether 
the  affection  is  ever  the  result  of  a  pure  neurosis,  though  it  is  often 
impossible  to  determine  its  exact  pathological  nature.  Diabetes  is  fre- 
quently a  cause  of  pruritis,  and  it  is  sometimes  due  to  vegetable  parasites, 
such  as  the  leptothrix  vaginalis  or  the  oidium  albicans.  In  some  cases  of 
chronic  vulvitis  pathological  changes  occur  in  the  papillae  of  the  skin  ; 
especially  in  the  fossa  navicularis,  on  the  hymen,  and  in  the  neighbour- 
hood of  the  urethral  orifice.  The  altered  condition  of  the  papillse  per- 
sists and  is  a  constant  source  of  irritation. 

There  are  cases,  however,  in  which  no  pathological  cause  is  discover- 
able, and  which,  in  the  present  state  of  our  knowledge,  must  be  regarded 
as  primary  neuroses.  This  primary  pruritis  is  most  frequently  found  in 
women  about  the  menopause;  very  rarely  in  young  women.  The  chief 
symptoms  are  itching  and  burning  in  and  about  the  labia,  especially  in 
the  clitoris  and  its  immediate  neighbourhood  ;  but  sometimes  it  spreads 
over  the  mons  veneris,  thighs,  and  anal  region.  The  itchiness  is  seldom 
constant,  but  mostly  occurs  in  paroxysms.  It  is  aggravated  by  warmth 
or  motion,  and  is  most  marked  at  night.  It  attains  its  greatest  intensity 
during  sexual  intercourse.  So  intolerable  does  this  itchiness  become  at 
times  that  women  affected  with  it  can  hardly  refrain  from  scratching  even 
in  public,  and  occasionally  their  condition  becomes  such  a  miserable  one 
that  in  order  to  escape  from  it  some  have  committed  suicide. 

The  first  and  most  important  step  in  treatment  is  to  try  to  discover 
the  cause.  But  even  where  no  cause  is  discoverable  local  treatment 
may  give  relief.  Batliing  with  carbolic  lotion,  corrosive  sublimate 
('^^^),  boric  acid  lotion,  or  lotion  of  su})acetate  of  lead,  has  been 
found    useful.     Painting  with  a  strong   solution    of   carljolic   acid,  or 


DISEASES   OF   THE   EXTERNAL    GENITAL    ORGANS  379 

nitrate  of  silver,  or  with  tincture  of  iodine ;  or  powdering  the  parts  with 
iodoform  and  tannic  acid,  have  been  known  to  give  relief.  Scanzoni 
recommended  painting  withchloroform  liniment — two  parts  of  chloroform 
to  sixty  of  oleum  amygdalae.  Equal  parts  of  powdered  alum  and  sugar 
mixed  and  dusted  over  the  parts  is  another  method  of  treatment.  Baths 
do  good.  All  rubbing  and  scratching  should,  as  far  as  possible,  be 
avoided.  Relief  from  the  itching  may  be  given  by  the  application  of  an 
ointment  of  cocaine.  Internally  bromide  of  potassium,  and  occasionally 
sulphonal  and  morphia,  have  been  of  service.  In  some  cases  arsenic  has 
done  good.  In  a  few  cases,  where  the  itchiness  was  limited  to  portions 
of  the  mucous  membrane,  benefit  has  followed  extirpation.  Fehling 
removed  both  labia  majora  and  the  clitoris  in  an  obstinate  case  of  pruritis 
with  permanent  benefit.  A  weak  galvanic  current  deserves  a  trial,  the 
anode  being  placed  on  the  vulvae,  and  the  kathode  applied  to  the  various 
affected  parts ;  good  results  from  this  method  of  treatment  have  been 
recorded.     The  general  health  should  be  attended  to. 

Venereal  Diseases.  —  Soft  chancre  generally  appears  shortly  after 
infection,  usually  within  twenty-four  hours.  It  is  a  small  vesicle  or 
pustule,  often  overlooked,  which  leaves  a  rapidly  spreading  ulcer  with 
a  yellowish  base,  bright  red,  sharply  defined,  or  undermined  edge,  and 
a  thick  purulent  discharge.  Soft  chancre  may  be  single,  but  it  is 
generally  multiple.  With  appropriate  treatment  it  heals  in  a  few  days  ; 
though  in  tuberculous  and  alcoholic  patients  it  has  a  tendency  to  slough 
or  to  assume  a  phagedaenic  form.  The  microscope  reveals  enlarged 
vessels  and  hypertrophied  papillae  in  the  neighbourhood  of  the  ulcer, 
whilst  those  on  the  surface  are  imdergoing  a  process  of  necrosis.  These 
chancres  may  occur  in  any  part  of  the  vulva.  One  inguinal  gland 
is  usually  inflamed  and  generally  suppurates. 

Syphilis  manifests  itself  in  a  hard  chancre  and  the  eruptions  of 
secondary  and  tertiary  syphilis.  The  hard  chancre  usually  appears  after 
a  period  of  incubation  of  about  one  month  from  the  time  of  infection  as 
a  little  indolent  red  spot,  the  base  of  which  becomes  indurated,  feeling 
like  cartilage.  It  rarely  assumes  a  papular  form,  but  more  frequentlj^ 
that  of  an  ulcer.  As  a  rule  the  surface  of  the  chancre  is  on  a  level  with 
that  of  the  neighbouring  tissue.  It  is  usually  single,  but  occasionall)' 
mnlti})le. 

Secondary  syphilis  occurs  as  superficial  erosions,  from  the  size  of 
a  millet  seed  to  that  of  a  sixpence  {plaques  muqueuses),  and  papular 
syphilides.  Tertiary  syphilis  occurs  in  the  form  of  gummata.  These 
tumours  appear  at  first  as  nodules  which  soften  and  ulcerate. 

For  the  constitutional  treatment  of  syphilis  I  must  refer  the  reader 
to  works  on  that  subject.  Locally  these  affections  may  be  dusted  with 
antiseptic  powder,  or  cauterised  with  nitrate  of  silver. 

TuMouus  OF  THE  YuLVA.  —  Inguinal  hernia,  though  less  common  in 
women  than  femoral,  is  not  very  rare.     The  bowel  may  descend  into  the 


3So 


SYSTEM   OF  GYNAECOLOGY 


greater  labiiun  through  the  canal  of  Nuck,  when  it  is  called  hernia  labii 
majoris  anterioris,  in  contradistinction  to  the  second  form,  which  descends 
through  thepel  vie  diaphragm  and  is  termed  hernia  labii  majoris  posterioris. 


Fk;.  117. —  Descent  of  |HTiiicul  luM-nhi  in  fnmt  oftlK^  hroud  lif,nuiicnt. 

This  latter  form  is  exceedingly  rare.  It  may  occur  in  two  ways:  — 
Firstly,  tlie  hernia  may  descend  in  front  of  the  liganuintum  latum,  dis- 
tendingthevesico-uterinefoldof]:)eritoneuin,audpassing  down  between  the 
bladder  and  uterus  along  the  vagina  into  the  labium  (vagino-labial  hernia)  ; 
or  it  may  descend  l)ehind  the  ligamentum  latum  between  the  rectum  and 


DISEASES    OF    THE   EXTERNAL    GENITAL    ORGANS  381 

vagina  either  into  the  labium  or  into  the  perineum.  The  hernia  may 
contain  the  uterus  and  ovaries  as  well  as  intestine  and  omentum.  The 
diagnosis  is  of  great  importance,  posterior  labial  hernia  being  especially 
liable  to  be  mistaken  for  cysts  of  Bartholin's  glands.  The  annexed 
photograph,  taken  from  a  patient  in  the  Rotunda  Hospital,  shows  a 
large  perineal  hernia  which  had  descended  in  front  of  the  broad  ligament. 
About  half  the  contents  could  be  reduced  into  the  abdominal  cavity,  and 
as  they  again  descended  into  the  sac  could  be  felt  through  the  vaginal 
wall. 

Varicocele  is  a  very  common  result  of  pregnancy,  tumours,  and  con- 
stipation. This  condition  seldom  gives  rise  to  much  disturbance.  The 
patient  complains  of  a  feeling  of  weight  and  distension  often  attended  by 
itching.  The  chief  danger  is  rupture  of  a  vein,  cases  of  fatal  result 
having  been  recorded  as  following  this  accident. 

Compression  of  the  veins,  so  useful  in  varicose  condition  of  the  lower 
extremities,  is  difficult  to  carry  out  in  this  situation.  A  T  bandage  and 
compress  is  so  inconvenient  that  it  can  only  be  adopted  in  the  Avorst  cases. 
We  are  obliged  to  restrict  our  measures  to  rest  in  bed  and  the  use  of 
astringent  washes.  In  case  of  rupture  haemorrhage  should  be  controlled 
at  once  by  the  application  of  a  compress  and,  as  soon  as  the  necessary 
preparations  can  be  carried  out,  by  ligature. 

Haematoma,  or  thrombus  vulvae,  generally  occurs  during  labour 
from  the  rupture  of  varicose  veins,  blows,  or  wounds.  Aii  elastic 
globular  tumour  of  a  deep  purple  colour  forms  in  the  labium  which 
is  neither  hot  nor  tender.  This  is  accompanied  by  a  feeling  of  tension 
and  a  desire  to  urinate.  The  tumour  may  burst,  or  there  may  be 
internal  haemorrhage  without  rupture  of  the  tumour.  In  either  case 
the  patient  frequently  bleeds  to  death.  Should  she  survive,  putrefaction 
of  the  effused  blood  may  occur  with  symptoms  of  sapraemic  infection  or 
acute  pyaemia. 

In  small  effusions  an  ice-bag  may  be  applied;  but  in  more  severe 
cases  it  is  better  to  lay  open  the  cyst  by  a  free  incision  and  control 
the  haemorrhage  by  suture,  or  by  firmly  packing  the  cavity  with  gauze. 
Should  symptoms  of  putrefaction  or  suppuration  occur  the  cyst  should  be 
thoroughly  evacuated,  disinfected,  and  treated  in  a  similar  manner. 

Warty  condylomata  are  generally  the  result  of  venereal  infection, 
but  may  occur  independently  of  this  cause,  especially  in  infants  and 
pregnant  women.  They  usually  commence  in  the  folds  between  the 
labia  majora  and  minora.  They  sometimes  occur  singly,  but  are  often 
agglomerated  so  as  to  form  very  large  tumours.  There  is  hypertropliy 
of  the  papillary  layer  of  the  skin.  They  may  spread  over  the  hymen, 
the  perineum,  and  around  the  urethra  and  anus.  The  symptoms  are 
not  very  pronounced,  and  are  chiefly  due  to  the  irritating  discharge. 
Large  tumours  cause  a  feeling  of  weight ;  but  as  a  rule  patients  only 
complain  of  burning  and  smarting.  These  growths  nuiy  be  dusted  with 
an  astringent  antiseptic  powder,  but  the  most  satisfactory  method  is 
their  total  removal  with  scissors  or  knife. 


3S2  SYSTEM  OF  GYNECOLOGY 

Elephantiasis  is  a  disease  seldom  met  with  in  these  countries.  It  is 
characterised  by  a  local  hyperplasia  of  the  skin,  and  by  an  increase  of 
subcutaneous  connective  tissue.  The  surface  is  sometimes  smooth  and 
shining  —  elephantiasis  glabra ;  sometimes  warty  —  elephantiasis  verru- 
cosa ;  sometimes  covered  with  projections — elephantiasis  papillomatosa : 
sometimes  the  swelling  feels  hard,  at  other  times  soft.  The  lymphatics 
are  enlarged,  and  there  is  a  small-celled  infiltration  around  the  blood- 
vessels, especially  round  the  veins,  with  an  increase  of  connective  tissue. 
It  is  not  certain  whether  the  lymphatic  dilatation  is  a  primary  or  secondary 
affection. 

Etiology.  —  Very  little  is  known  of  the  causation  of  this  disease,  but 
the  fact  that  it  is  endemic  in  certain  countries  points  to  infection.  It 
usually  begins  between  the  ages  of  15  and  40,  but  has  been  known  to 
begin  in  infancy.  Various  causes  have  been  assigned,  such  as  syphilis, 
soft  chancre,  scrofula,  masturbation,  and  various  inflammations,  especially 
erysipelas.  None  of  them,  however,  occurs  with  sufficient  constancy  to  be 
accepted  as  an  undoubted  cause. 

Symptoms.  —  In  hot  climates  the  disease  often  commences  as  an  acute 
affection,  but  not  so  with  us.  The  hypertrophy  is  attended  by  itching, 
smarting,  and  some  discharge ;  but  the  patients  chiefly  complain  of  a 
feeling  of  weight  due  to  the  size  of  the  tumour,  which  also  causes  diffi- 
culty in  walking,  cohabitation,  micturition,  and  defsecation. 

Diagnosis.  —  This  disease  is  liable  to  be  confounded  with  other  hyper- 
trophic skin  diseases  associated  with  ulceration,  especially  with  lupus  and 
cancer.  In  both  these  affections  the  ulceration  is  more  extensive,  and  in 
the  latter  case  it  runs  a  much  more  rapid  course. 

Treatment. — Elephantiasis  is  essentially  a  chronic  disease,  and,  ex- 
cepting from  some  complication,  does  not  endanger  life.  It  does  not, 
however,  yield  to  treatment;  and  strapping,  which  Hebra  found  so 
beneficial  when  the  disease  involved  the  lower  extremities,  can  seldom  be 
employed  where  it  attacks  the  vulva.  The  only  treatment  likely  to 
give  relief  is  total  removal.  This  is  best  accomplished  by  the  procedure 
introduced  by  Schroeder,  namely,  to  begin  at  the  posterior  limit  of  the 
disease  and  remove  it  bit  by  bit,  closing  each  portion  of  the  bleeding 
wound  by  suture. 

Lupus.  —  If  we  limit  the  name  lupus  to  disease  undoubtedly  tubercular, 
thenlupusof  the  vulva  is  almost  wholly  unknown.  In  one  case  only  were 
tubercle  bacilli  demonstrated,  namely',  by  Viatte  in  1891.  In  another  case 
giant  cells  and  caseous  degeneration  were  observed  by  Birch-Hirschfeld  ; 
but  in  the  great  majority  of  cases  commonly  called  lupus  no  tubercular 
disease  is  demonstrable.  Such  cases  ai'e  characteriseil  ))y  infiltration  of 
the  mucous  membran(^,  which  soon  ulcerates,  and  the  ulceration  si)r(!ads 
superficially,  often  healing  in  one  place  while  it  extends  in  another.  The 
disease  usually  commences  in  the  labia  minora,  spreading  gradually  to  the 
clitoris  and  vagina.  The  ulcers  are  often  excavated  with  jagged  edges. 
The  base  is  sometimes  red,  sometimes  yellowish,  and  covered  with  small 
nodules  or  polypoid  outgrowths.     The  vesico-vaginal  and  recto-vaginal 


DISEASES   OF   THE  EXTERNAL    GENITAL    ORGANS  383 

walls  are  often  the  seat  of  infiltration  leading  to  ulceration,  whicli 
frequently  causes  fistula. 

Symx)toms.  —  At  first  the  symptoms  are  not  well  marked.  "VVhcu 
ulceration  occurs  there  are  irregular  haemorrhages  and  leucorrhoea,  but 
rarely  pain.  The  progress  is  slow  ulceration,  healing  in  one  direction. 
whilst  it  extends  in  another. 

Diagnosis.  —  Syphilis  is  distinguished  by  the  general  symptoms 
and  history,  and,  in  doubtful  cases,  by  a  course  of  special  treatment. 
Cancer  is  distinguished  by  its  more  rapid  growth,  its  general  appear- 
ance, glandular  implications,  and  deeper  idceration.  In  elephantiasis 
hypertrophy  rather  than  ulceration  is  the  chief  feature,  and  it  most 
frequently  involves  the  labia  majora ;  whereas  lupus  is  characterised 
more  by  ulceration  than  hypertrophy,  and  the  lesser  labium  is  pi-i- 
marily  affected. 

Treatment.  —  The  only  successful  treatment  consists  in  the  rem(n-al 
of  the  disease  either  by  the  knife,  by  curettage,  or  by  the  actual  or  poten- 
tial cautery ;  but  where  the  disease  involves  the  vesico-vaginal  or  recto- 
vaginal septum  the  greatest  possible  care  must  be  taken  not  to  open 
either  the  bladder  or  the  rectum,  as  the  diseased  structures  will  not 
readily  unite;  indeed,  it  would  probably  be  found  impossible  to  repair 
such  an  injury. 

Malignant  disease  occurs  in  the  form  of  epithelioma,  medullary 
cancer,  scirrhus,  and  sarcoma.  Primary  cancer  of  the  vulva  is  com- 
paratively rare ;  but  of  the  forms  mentioned  epithelioma  is  much 
the  most  frequent.  It  begins  generally  in  the  larger  labium,  or  in  the 
cleft  between  the  labia  majora  and  minora,  where  the  cutaneous  and 
mucous  structures  become  continuous.  It  first  appears  in  the  form  of 
little  nodules  in  the  skin  which  become  warty,  shed  their  epithelium, 
and  discharge  a  watery  fluid  tinged  Avith  blood.  An  ulcer  forms  which 
spreads  superficially  at  first,  but  later  extends  more  deeply,  and  involves 
the  neighbouring  structures.  The  inguinal  glands  in  the  early  stage  of 
the  disease  become  sympathetically  enlarged ;  subsequently  the  enlarge- 
ment is  due  to  infiltration.  At  first  the  disease  is  confined  to  one  side, 
but  the  opposite  labium  becomes  involved  in  many  cases,  probably 
through  inoculation. 

Symptoms.  —  The  earliest  symptom  is  pruritus,  more  particularly 
when  the  clitoris  is  involved.  The  ulceration  and  discharge  cause  dis- 
comfort; but  pain  is  seldom  complained  of  until  the  disease  is  far 
advanced.  Haemorrhage  is  a  late  symptom  and  one  that  rarely  proves 
fatal.  Death  occurs  in  the  majority  of  cases  from  marasmus  attributa- 
ble to  chronic  septic  infection,  and  metastasis. 

Prognosis. — The  prognosis  is  bad;  however,  a  few  permanent  cures 
after  operation  have  been  recorded. 

Treatment.  —  Total  removal  of  the  disease  is  the  only  method  of 
treatment  which  holds  out  a  prospect  of  cure.  Birschoff  has  recorded 
good  results  from  the  galvano-cautery.  Most  operators  prefer  the  knife ; 
but  if  cancer  be  inoculable,  then  the  destruction  of  the  disease  with  the 


384  SYSTEM   OF  GYNECOLOGY 

actual  cautery  affords  a  better  prospect  of  radical  cure  than  any  cutting 
operation. 

In  cases  where  operation  is  undesirable,  the  putrid  and  irritating 
discharge  can  be  controlled  for  a  time  by  scraping  and  the  cautery. 
Where  the  disease  is  too  far  advanced  for  this  treatment,  the  ulcers 
may  be  sprinkled  with  equal  parts  of  iodoform  and  charcoal,  and 
dressed  with  absorbent  gauze. 

Fibroids  occur  most  frequently  in  the  larger  labia,  but  are  some- 
times found  upon  the  perineum  and  the  nymphae.  These  tumours  are 
encapsuled,  and  consist  of  muscular  and  connective  tissue-;  sometimes 
they  attain  large  dimensions  and  become  pedunculated.  Although 
these  tumours  are  not  in  themselves  dangerous  to  life,  yet  sometimes 
the  inconvenience  due  to  their  weight  and  position  render  their  removal 
advisable. 

Lipoma.  —  The  favourite  site  of  these  tumours  is  the  neighbourhood 
of  the  mons  veneris  and  larger  labia.  In  appearance  they  resemble 
elephantiasis,  but  on  extirpation  they  are  found  to  consist  of  fatty  tissue. 

Enchondroma. — Enchondroma  of  the  clitoris.  One  case  has  been 
recorded  by  Schneevogt.  Ossification  of  the  clitoris  mentioned  by 
Beidel  is  probably  of  this  nature. 

Neuroma.  —  Simpson  has  described  one  case  and  Kennedy  another. 

Angioma.  —  This  variety  of  tumour  is  exceedingly  rare. 

Cysts.  —  Apart  from  the  cysts  of  Bartholin's  glands,  other  cysts 
occur  in  the  labia  and  neighbouring  region;  however,  they  are  com- 
paratively rare,  and  are  due  to  obstructed  glands,  haemorrhage,  or 
dilated  lymphatics. 

Kraurosis  Vulvae.  —  Our  knowledge  of  this  affection  is  due  to  the 
late  Professor  Breisky  of  Prague,  Dr.  Martin  of  Berlin,  and  his  assist- 
ant Dr.  Orthman.  It  is  characterised  by  a  peculiar  atrophic  shrinking 
of  the  integuments  of  the  external  genitals  and  perineum,  resulting  in 
obliteration  of  the  normal  folds. 

The  tissues  affected  become  dry,  shrink,  lose  their  normal  elasticity, 
and  become  so  brittle  that  the  most  careful  examination  may  cause 
deep  fissures.  The  surface  assumes  a  whitish  macerated  shining 
appearance. 

The  microscopic  examination  reveals  atrophy  of  the  corium,  espe- 
cially of  its  upper  layer.  The  papillae  are  ill-developed,  and  the  rete  layer 
so  thin  that  the  epidermis  lies  directly  itpon  the  papillae.  The  seba- 
ceous glands  are  absent,  and  only  a  few  remnants  of  sweat  glands 
remain.  There  is  found  a  small  celled  infiltration  of  the  papillae  in 
the  deeper  layer  of  the  corium.  At  the  margin  of  the  disease  Orthman 
found  the  tissues  hypertrophied,  a  small  celled  infiltration  of  the  corium, 
and  a  flattening  out  of  the  papillae. 

Symptxjm.H.  —  In  some  cases  symptoms  are  slight  or  absent ;  but  gener- 
al ly  tliei-e  is  a  most  unpleasant  itching  and  Irurning  sensation,  especially 
during  micturition,  and  occasionally  an  irritating  discharge.  Owing  to 
the  narrowing  of  the  vulva,  and  the  tenderness,  rigidity,  and  brittleness 


DISEASES   OF  THE  EXTERNAL    GENITAL    ORGANS  385 

of  the  tissues,  the  disease  may  render  coitus  excessively  painful  or 
impossible.     The  cause  of  this  condition  is  unknown. 

Treatment.  —  This  disease  does  not  yield  to  any  remedy,  but  removal 
of  the  tissues  involved  has  been  followed  by  complete  relief  without  any 
subsequent  recurrence. 

Vaginitis,  Colpitis,  or  Elytritis.  —  The  Normal  Vaginal  Discharge. 

—  In  its  healthy  state  the  vagina  contains  a  discharge,  to  the  character 
and  nature  of  which  Doderlein  has  given  special  attention.  He  restricts 
the  term  normal  to  a  discharge  having  the  following  main  features  :  — 
It  is  a  whitish  gray  material,  of  the  consistency  of  clotted  milk,  of 
intensely  acid  reaction,  and  containing  an  almost  pure  culture  of  the 
vaginal  bacillus ;  of  other  micro-organisms,  the  odium  albicans  and  the 
yeast  fungus  can  occasionally  be  detected.  Saprophytes  are  rapidly 
destroyed  in  this  material,  probably  owing  to  its  acidity.  It  never 
yields  pathological  germs  by  culture ;  and  its  injection  into  animals  is 
followed  by  equally  negative  results.  In  describing  this  discharge  I 
have  purposely  avoided  the  term  secretion,  for,  in  connection  with  a 
membrane  practically  destitute  of  glands,  it  seems  to  me  incorrect  to 
adopt  that  term ;  it  is  more  proper  to  consider  it  as  an  exudation 
from  the  general  vaginal  surface.  Be  this  as  it  may,  its  exact  source 
remains  a  question  of  uncertainty.  It  has  been  asserted  by  some  authors 
that  it  comes  from  the  cervix  and  from  the  vulvo-vaginal  glands ;  but 
the  absence  of  mucus  from  its  component  elements  negatives  such  a 
hypothesis. 

The  pathological  discharge,  which  is  an  important  symptom  of 
vaginitis,  but  is  found  independently  of  that  affection,  is  of  a  yellow 
or  greenish  yellow  colour,  of  creamy  consistency,  sometimes  froth}',  or 
mixed  with  viscid  mucus,  feebly  acid  or  even  alkaline  in  reaction,  and 
contains  various  micro-organisms.  The  essential  distinction  between  the 
normal  and  the  abnormal  discharge  is,  that  whereas  saprophytes  perish 
rapidly  in  the  former  material,  the  latter  constitutes  an  environment 
peculiarly  favourable  to  their  growth.  It  is,  therefore,  evident  that  the 
vaginal  discharge  must  be  modified  before  it  can  become  a  soil  suitable 
to  the  life  and  development  of  saprophytes  and  other  germs.  Such  a 
modification  is  effected  by  the  copious  alkaline  efflux  which  descends 
from  the  uterine  cavity  during  menstruation,  child-bed,  uterine  catarrh, 
and  cancer ;  or  from  the  cervix  when  that  part  is  in  a  state  of  catarrhal 
inflammatioii.  In  the  diseases  last  mentioned  the  germs  for  the  most 
part  reach  the  seat  of  pathological  change  through  the  vagina;  but  so 
long  as  the  vaginal  discharge  is  normal  that  structure  maintains  its  in- 
tegrity. Sexual  intercourse  often  conveys  noxious  matter  into  the 
vagina  —  sai)vophytes,  tubercle  bacilli,  and  other  germs;  but,  contrary 
to  what  might  have  been  expected,  even  in  gonorrha^a  the  vagina  is 
seldom  primarily  affected,  but  becomes  so  secondarily  from  the  uterus, 
the  vulva,  or  the  urethra.  No  doubt  the  anatomical  structure  of  the 
membrane  helps  to   preserve  it  from  invasion ;    which  is  much  more 

2c 


386  SYSTEM  OF  GYNECOLOGY 

likely  to  occur  -when  it  is  altered  by  constant  contact  witli  copious 
iiTitatiug  discharges  such  as  flow  from  the  uterus  in  cancer,  sloughing 
myoma,  and- septic  puerperal  affections,  or  by  irritating  alkaline  urine 
and  faeces  in  ui-inary  and  faecal  iistulae.  Similarly  foul,  ill-fitting,  or 
neglected  pessaries  —  especially  those  made  of  soft  rubber  or  wood  — 
neglected  tampons  and  other  foreign  substances,  the  actual  or  potential 
cautery,  vaginal  douches  when  used  too  hot  or  with  foul  vaginal  tubes, 
gynaecological  manipulation  with  septic  hands  and  instruments,  not  only 
remove  or  destroy  the  normal  vaginal  discharge,  but  macerate  and  irri- 
tate the  mucous  covering,  and  lead  to  exfoliation  of  the  epithelium  and 
other  anatomical  changes  which  render  the  part  liable  to  the  invasion  of 
disease.  Certain  constitutional  diseases,  such  as  tuberculosis,  dispose  to 
leucorrhoea ;  and  the  exanthemata,  as  well  as  erysipelas,  diphtheria,  and 
dysentery,  must  be  included  amongst  the  causes  of  vaginitis. 

Simple  Catarrh.  —  In  this  disease,  when  acute,  the  mucous  membrane 
is  uniformly  swollen,  a]id  of  a  bright  red  colour ;  the  rugae  are  exaggei'- 
ated  ;  there  is  a  small  celled  infiltration  of  the  epithelial  structures,  and 
a  shedding  of  epithelial  cells.  The  discharge  is  feebly  acid  or  alkaline. 
It  contains  leucocytes  and  other  micro-organisms,  besides  desquamated 
epithelium.  When  chronic  it  appears  to  have  a  selective  affinity  for  the 
anterior  vaginal  wall,  and  the  signs  and  syniptojus  are  less  marked. 
Granular  vaginitis  is  often  gonorrhoeal,  and  is  most  marked  in  pregnant 
women.  The  papillae  are  hypertrophied,  infiltrated  with  small  cells, 
and  fused  together  so  as  to  form  the  so-called  granulations,  the  ej^ithelial 
covering  of  which  is  shed  so  that  they  assume  a  dark  red  colour. 

Gonorrhoeal  Vaginitis.  —  The  mucous  membrane  is  red,  hot,  and 
swollen;  the  discharge,  which  is  profuse,  is  at  first  creamy,  but  be- 
comes purulent  with  the  progress  of  the  disease.  The  papillae  are 
evident  to  the  sight  and  touch.  Gonococci  are  found  in  the  discharge, 
and  in  the  epithelial  cells  and  leucocytes.  In  the  chronic  form  the 
disease  is  generally  confined  to  the  fornices  and  vulvo-vaginal  glands. 

Vaginitis  vetularum  vel  adhesiva  is,  as  its  name  implies,  peculiar 
to  women  who  have  passed  the  menopause.  The  membrane  is  smooth, 
reddish,  and  atrophied  in  patches  which  are  denuded  of  epithelium. 
These  denuded  surfaces  are  due  to  defective  nutrition  rather  than  to 
the  action  of  micro-organisms  ;  and  they  tend  to  grow  together,  forming 
firm  adhesions.  In  some  cases  the  fornices  become  entirely  obliterated 
by  their  surfaces  growing  together,  or  by  their  adhesion  to  the  cervix; 
in  other  cases  the  adhesion  occurs  so  low  in  the  vagina  that  the  cervix 
can  be  neither  felt  nor  seen.  When  recent  the  adhesions  may  be  broken 
down  and  the  natural  shape  of  the  vagina  restored;  but,  as  a  rule, 
this  will  be  found  impossiV^le.  This  form  of  vaginitis  is  so  common 
that  few  women  over  sixty  years  of  age  will  be  found  without  some 
adhesions. 

tSyiaplomft  of  Var/inal  Catarrh.  —  In  the  acute  form  the  ])atient  com- 
plains of  hot  and  burning  feelings,  accomi)anied  with  a  bearing-down 
sensation  with  increased  secretion,  at  first  serous,  then  mucous,  muco- 


DISEASES    OF   THE   EXTERNAL    GENITAL    ORGANS  387 

purulent,  and  often  purulent.  The  vulva  is  generally  involved,  and 
sometimes  the  urethra,  in  which  case  the  patient  complains  of  frequent 
and  painful  micturition.  In  chronic  vaginitis  the  profuse  discharge  is 
what  the  patients  chiefly  complain  of.  In  adhesive  vaginitis  there  are 
no  symptoms  except  occasionally  a  thin  discharge. 

Physical  Signs.  —  The  linger  feels  the  soft  and  swollen  membrane 
and  consequent  narrowing  of  the  canal.  In  the  granular  form  the 
hypertrophied  papillae  feel  like  granules  upon  the  surface.  When  the 
specukun  is  passed,  the  membrane  is  observed  to  be  red  and  swollen, 
and  the  foldings  exaggerated.  In  some  cases  bright  red  papillaj  pro- 
trude above  the  surface,  and  a  fair  estimate  can  be  formed  of  the  amount 
and  character  of  the  discharge.  In  the  senile  form  the  adhesions  can 
be  detected  by  the  finger. 

Prognosis.  —  Vaginitis  may  be  regarded  as  a  curable  disease  in  every 
case  in  which  the  cause  of  it  is  remediable.  The  prognosis  is  doubtful 
in  cases  of  gonorrhoeal  vaginitis,  because  the  disease  in  the  cervix,  in 
the  vulvo-vagiual  glands,  and  in  the  husband,  may  not  be  curable ;  and 
it  is  absolutely  bad  when  the  affection  is  due  to  persistent  irritating  dis- 
charges, as  in  incurable  fistula  and  cancer. 

Fi'02)hylaxis.  —  Amongst  prophylactic  measures  the  most  important 
are,  firstly,  to  prohibit  marriage  to  men  suffering  from  gonorrhoea  for  at 
least  two  years  from  the  time  of  infection ;  and  if  Veit's  observations 
be  correct,  it  is  almost  as  important  that  a  woman  who  has  been  infected 
with  gonorrhoea  should  cease  to  cohabit  with  her  husband  until  both 
have  been  cured.  The  third  point  is  the  importance  of  asepsis  in  minor 
practice ;  the  avoidance  of  routine  douching,  and  care  in  the  use  of  pes- 
saries, plugs,  specula,  and  other  instruments. 

Local  Treatment.  —  In  treating  a  patient  who  has  actually  acquired 
vaginitis,  the  method  to  be  pursued  will  vary  not  only  with  the  kind 
of  inflammation,  but  also  with  the  condition  in  which  it  may  present 
itself  —  whether  acute  or  chronic,  a  fresh  inflammation  or  one  of  long 
standing.  The  first  duty  of  the  practitioner  will  be  to  remove  the 
cause  of  the  inflammation  provided  that  it  can  be  discovered.  He  should 
remove  pessaries  and  plugs,  cure  fistulse,  and  treat  cervical  and  other 
diseases  which  may  be  the  causes  of  the  vaginitis. 

In  acute  vaginitis  the  vagina  may  be  irrigated  with  mild  antiseptic 
douches,  either  hot  or  cold.  The  most  frequently  used  are  corrosive 
sublimate  (1  in  2000),  carbolic  acid  (2  per  cent),  creoline  or  lysol  (1  per 
cent),  salicylic  acid  (^V  per  cent),  boric  acid  (3  per  cent) ;  should  these 
be  too  irritating,  lead  lotion  or  permanganate  of  potash  may  be  sub- 
stituted. In  many  cases  no  antiseptic  at  all  can  be  tolerated ;  in  these 
the  vagina  is  irrigated  with  plain  water,  gruel,  or  linseed  tea.  As  acute 
vaginitis  is  always  accompanied  by  vulvitis,  sitz  baths,  rest  in  bed,  and 
other  treatment  adapted  to  this  condition  must  be  used  at  the  same  time. 

Subacute  or  chronic  vaginitis  is  best  treated  by  local  applications 
applied  through  a  speculum,  the  patient  lying  upon  her  back.  A  cylin- 
drical speculum  docs  very  well ;  but  a  modification  of  Sims'  speculum, 


388  SYSTEM  OF  GYNECOLOGY 

lined  with  platiniuu  or  made  of  vulcanite,  is  better :  by  means  of  this 
instrument  the  perineum  is  drawn  backwards,  and  the  vagina  then  filled 
with  the  solution.  The  best  applications  for  this  purpose  are  crude 
pyroligneous  acid  of  commerce,  or  solution  of  sulphate  of  copper  (2  to 
5  per  cent).  In  gonorrhoeal  cases  nitrate  of  silver  (5  per  cent)  is 
appropriate.  In  some  cases  benefit  results  from  painting  the  surface 
of  the  vagina  with  tincture  of  iodine,  or  dusting  it  with  iodoform  or 
other  antiseptic  powders.  In  very  chronic  cases  astringents  will  be 
found  more  useful  than  antiseptics ;  amongst  these  may  be  mentioned 
dermatol,  tannin,  or  alum  and  sugar  in  equal  parts.  These  are  best 
applied  in  powder.  Astringent  injections  may  be  employed  by  the 
patient  herself;  amongst  the  most  useful  of  these  are  douches  contain- 
ing alum,  sulphate  of  zinc,  borax,  and  oak  bark.  In  other  cases  we  may 
use  pessaries,  made  of  cocoa  butter  or  glycerine  and  gelatine,  contain- 
ing the  antiseptic  or  astringent  application  desired.  This  method  is 
more  popular  than  it  otherwise  would  be,  as  the  patient  herself  can 
readily  introduce  the  remedy ;  but  oily  substances  are  bad  vehicles  for 
antiseptic  remedies.  If  made  with  glycerine  and  gelatine,  which  is  the 
form  I  prefer,  they  require  considerable  skill  in  manufacture  ;  or  they 
may  either  melt  between  the  fingers  before  they  can  be  introduced  into 
the  vagina,  or  they  may  not  melt  at  all,  and  be  voided  unchanged. 

Colpitis  Mycotica.  —  Vaginitis  is  sometimes  due  to  micro-organisms, 
of  a  higher  order  than  bacteria,  which  flourish  in  the  acid  vaginal  dis- 
charge :  such  are  the  monilia  (oidium)  albicans,  monilia  Candida,  and 
leptothrix  vaginalis. 

This  form  of  vaginitis  is  found  most  frequently  in  pregnant  women 
with  gaping  vulvae,  torn  perineums,  and  vaginal  prolapse.  It  occurs 
more  often  in  summer  than  in  winter,  and  has  been  attributed  to  damp 
dwellings.  The  parasites  are  generally  conveyed  to  the  patient  by  the 
air  or  by  the  fingers,  especially  when  the  latter  are  soiled  with  meal  or 
flour.  Similarly  a  woman  whose  infant  is  suffering  from  thrush  may 
infect  herself ;  or  again,  the  disease  may  be  communicated  during  coitus, 
especially  if  the  husband  be  diabetic. 

Symptoms. — The  patients  complain  of  intense  burning,  smarting, 
and  itching.  In  the  majority  of  cases  there  is  little  or  no  discharge ; 
but  where  discharge  is  present  it  is  of  an  irritating,  excoriating 
character.  The  mucous  membrane  is  bright  red,  swollen,  and  covered 
with  little  white  patches  of  varying  size,  but  seldom  larger  than  a  pin's 
head,  and  excessively  tender  to  touch. 

Treatment  must  be  actively  antiseptic.  Douches  will  afford  little  or 
no  relief  ;  it  is  better  to  introduce  a  speculum  and  fill  it  with  solution  of 
corrosive  sublimate,  suljihate  of  copper,  or  nitrate  of  silver,  so  that  as 
it  is  slowly  withdrawn  the  parts  are  bathed  with  the  fluid.  ]?y  this 
means  a  cure  is  usually  effected  in  a  few  days. 

Emphysematous  vaginitis  occurs  as  little  cysts  containing  gas. 
Winckle,  who  first  described  the  disease,  gave  to  it  the  name  of  colpo- 
hyperi)lasia  cystica. 


DISEASES   OE   THE  EXTERNAL    GENITAL    ORGANS  389 

In  the  vagina  of  pregnant  women,  sometimes  in  child-bed,  or  even  in 
women  who  are  not  pregnant,  hemispherical  protuberances  with  a  smooth 
soft  surface,  which  occasionally  give  to  the  finger  the  emphysematous 
crepitation,  are  met  with  in  regular  groups  from  time  to  time,  especially 
on  the  anterior  wall,  in  the  upper  third  of  the  vagina,  and  on  the  mucous 
membrane  of  the  portio  vaginalis.  They  stand  upon  a  swollen  bright 
red  base,  and  are  often  surrounded  by  a  narrow  red  margin.  If  one  of 
these  little  vesicles  be  punctured  it  immediately  collapses  without  any 
escape  of  fluid,  but  occasionally  with  the  sound  of  escaping  gas.  This 
condition  is  classed  amongst  inflammations  because  of  the  attendant 
swelling  and  hypersecretion. 

Exfoliative  vaginitis  is  characterised  by  periodical  exfoliation  of  the 
epithelium  of  the  membrane,  and  is  usually  associated  with  dysmenor- 
rhoea.  It  was  first  described  by  Dr.  Farre  in  1858 ;  it  is  generally 
associated  with  and  probably  dependent  upon  hysteria. 

Diphtheritic  and  dysenteric  vaginitis  occur  rarely  as  complications  of 
these  diseases.  The  term  diphtheritic  is  often  erroneously  applied  to  a 
white  membrane  which  forms  in  the  vagina  in  some  cases  of  puerperal  in- 
fection ;  in  sloughing  cancer  and  myoma;  and  in  some  of  the  fevers,  espe- 
cially measles,  small-pox,  and  typhus.  Erysipelas  may  also  attack  the 
vagina. 

Phlegmonous  Peri- Vaginitis. — Here  the  peri-vaginal  cellular  tissue 
is  the  chief  seat  of  the  disease,  and  as  the  vaginal  tube  is  deprived  of 
its  nourishment  through  this  tissue,  it  necroses  and  is  thrown  off  as  a 
slough.  This  rare  affection  was  first  described  by  Marconnat,  but  its 
etiology  is  yet  obscure.  It  has  been  seen  to  foUow  the  exanthemata 
and  venereal  affections. 

Si/m2)toms.  —  Fever,  slight  haemorrhages,  or  putrid  discharge.  Pain 
is  always  present,  and  was  in  one  case  very  severe.  The  labia  are 
swollen  and  superficially  ulcerated.  The  vaginal  mucous  membrane 
is  swollen  and  pale,  discoloured  and  necrosed.  Most  reported  cases 
recovered,  and  were  not  followed  by  as  much  contraction  as  might  have 
been  expected. 

The  treatment  is  limited,  in  the  early  stage,  to  disinfection ;  in  the 
later  to  the  prevention  of  contraction  of  the  cicatrices.  There  is  a 
much  more  chronic  form  of  peri-vaginitis,  associated  with  chronic 
syphilis,  which  sometimes  leads  to  fistulous  communications  between 
the  vagina  and  rectum. 

Vaginismus  is  a  term  applied  to  an  abnormal  hyperaesthesia  of  the 
external  genital  organs,  causing  muscular  spasm.  It  occurs  chiefly  in 
young,  nervous,  and  hysterical  women.  It  is  sometimes  associated  with 
irritable  urethra,  or  with  a  rigid  hymen  which  has  become  irritated  and 
inflamed.  If  the  hymen  is  already  ruptured  the  carunculae  myrtiformes 
are  excessively  sensitive.  This  condition  has  been  attributed  to  fissure 
of  the  anus ;  and  to  incomplete  coitus,  resulting  from  imperfect  erection 
and  premature  ejaculation.     Sometimes  the  symptoms  are  due  to  spasm 


390  SYSTEM   OF  GYNECOLOGY 

of  the  perineal  and  levator  ani  muscles  on  attempted  copulation.  At 
other  times  there  is  a  feeling  of  weight  in  the  perineum;  h3^poehon- 
driacal  symptoms  are  also  present  as  a  rule.  A  form  of  vaginismus, 
attended  with  spasm  of  the  levator  ani  muscles,  has  been  described  as 
superior  vaginismus;  it  causes  the  very  unpleasant  complication  of 
penis  captivus. 

Treatment.  —  Where  a  local  cause  is  discoverable  efforts  should  be 
made  to  remove  it;  hydropathy,  potassium  bromide,  cocaine,  opium, 
and  belladonna  in  suppository,  have  been  found  of  benefit  in  removing 
the  spasm :  excision  of  the  carunculae  mja'tiformes  and  gradual  dilata- 
tion of  the  vulva  may  be  practised ;  or  the  patient  may  be  placed  under 
an  anaesthetic  and  the  vulva  forcibly  dilated  with  the  fingers.  Marion 
Sims  used  to  treat  these  cases  by  a  V-shaped  incision  of  the  posterior 
wall  of  the  vagina,  and  I  have  certainly  seen  benefit  follow  this  proced- 
ure or  some  modification  of  it.  Electricity  has  also  been  tried  with 
some  apparent  benefit. 

Tu3iouRS  OF  THE  Vagiin'A.  —  Tumours  of  the  vagina  are  of  the  fol- 
lowing kinds  —  cystoma,  tibromyoma,  carcinoma,  sarcoma,  tuberculosis. 

Simple  cysts  occur  in  the  majority  of  cases  as  small  tumours,  from 
the  size  of  a  cherry  stone  to  that  of  a  walnut ;  they  are  seldom  so  large 
as  the  fist  or  foetal  head.  Their  position  is  as  variable  as  their  size. 
They  are  generally  found  in  the  lower  half  of  the  vagina,  but  may  occur 
in  any  part.  The  origin  of  these  cysts  is  not  clear :  in  souie  cases  they 
originate  in  a  remnant  of  Mliller's  ducts ;  in  other  cases  they  may  be 
connected  with  the  Wolffian  or  Gartner's  ducts.  They  may  arise  as 
retention  cj^sts  connected  with  certain  glands  discovered  by  v.  Preuschen. 
Others  must  be  regarded  as  dilated  lymphatics,  or  extravasations  of 
blood. 

Cysts,  excepting  in  cystic  vaginitis,  are  generally  single;  but  some- 
times they  are  multiple.  They  are  covered  by  ordinary  mucous  mem- 
brane, which  may  be  so  thinned  by  expansion  that  the  contents  shine 
through ;  they  contain  mucus  either  clear  or  milky  from  admixture  of 
epithelium,  or  black  or  dark  from  admixture  with  blood ;  in  multilocu- 
lar  cysts  the  contents  are  often  various. 

Treatment.  —  Small  cysts  should  be  extiri)ated  ;  larger  ones  should 
have  their  surface  removed  to  the  level  of  the  vagina,  and  the  cyst  wall 
stitched  to  the  vaginal  mucous  membrane. 

Fibroids.  —  In  comparison  with  uterine  myoma  these  tumours  are 
rare.  They  most  frequently  occur  in  the  anterior  wall ;  at  first  they 
are  broad-based  and  sessile,  but  later  become  pedunculated.  They  vary 
in  size  from  a  pea  to  that  of  a  fcjetal  head  or  more. 

fSymptoms.  —  Small  tumours  cause  no  symptoms;  larger  ones  cause 
inconvenience  tlirougli  thcnr  weight  and  })r(!ssure  on  surrounding  struct- 
ures: they  may  cause  a  feeling  of  dragging,  dilliculty  in  walking  and 
sitting,  irritability  of  the  bladder  or  difficulty  in  emptying  it.  Obstruc- 
tion arises  to  t'oitus  ami  to  diild-birth. 


DISEASES   OF    THE   EXTERNAL    GENITAL    ORGANS  391 

Treatment  consists  in  operative  removal.  Polypi  are  removed  by 
cutting  through  the  pedicle  with  scissors  or  ecraseur.  Sessile  tumours 
should  be  enucleated.  The  cavity  left  may  be  closed  by  suture  after  all 
bleeding  vessels  have  been  ligatured  ;  or,  if  this  be  impracticable,  it  should 
be  plugged  with  iodoform  gauze. 

Carcinoma.  —  Primary  cancer  of  the  vagina  is  rare ;  secondary  cancer 
is  very  common.  The  former  occurs  as  a  papillomatous  growth  upon  a 
broad,  infiltrated  base  upon  the  posterior  wall,  or  as  a  firm,  annular 
constriction  or  uniform  infiltration  of  the  entire  vaginal  tube. 

The  etiolrxpj  is  unknown,  but  it  usually  occurs  between  the  ages  of  30 
and  60.     Child-bearing  has  not  any  influence  in  its  causation. 

Tlie  sijmptoms  are  the  same  as  those  attending  cancer  elsewhere.  The 
patients  complain  of  pain ;  watery  discharge  often  offensive  and  irritating ; 
haemorrhage,  especially  after  coitus  ;  and,  later,  implication  of  glands  and 
the  cancerous  cachexia. 

Tlie  prognosis  is  bad.  Patients  rarely  seek  advice  until  too  late  for 
successful  extirpation ;  and  even  when  removal  of  the  growth  has  been 
effected,  return  is  almost  certain.  Probably  the  best  method  of  operation 
in  these  cases  is  to  incise  the  perineum  transversely,  to  separate  the  vagina 
from  the  rectum  from  below,  to  a  point  above  the  upper  margin  of 
the  disease,  to  excise  the  detached  vaginal  wall,  and,  finally,  to  close  the 
wound  by  suture.  In  cases  too  far  advanced  for  extirpation,  the  disease 
should  be  scraped  away  as  far  as  possible  with  a  sharp  spoon  and 
cauterised  with  the  actual  cautery.  Great  care  must  be  taken  not  to 
injure  the  bladder  or  rectum,  as  a  fistula  could  scarcely  be  closed  again. 
In  many  cases  our  treatment  is  limited  to  antiseptic  douching  or  dry 
dressing. 

Sarcoma  is  even  rarer  than  primary  cancer,  and  is  remarkable  for  its 
occurrence  in  early  childhood  ;  it  has  even  been  supposed  to  be  congeni- 
tal. It  may,  however,  occur  at  any  age.  It  generally  attacks  the 
anterior  wall  in  children,  though  in  adults  it  occurs  as  often  on  the 
posterior  wall.  It  occurs  as  a  circumscribed  tumor,  a  fibrosarcoma,  or 
as  a  diffuse  infiltration.  The  disease  rapidly  spreads  to  the  bladder, 
rectum,  perineum,  and  external  genitals. 

Pathology.  —  Microscopically  both  round  and  spindle  cells  occur  with 
an  increase  of  connective  tissue.  The  disease  usually  originates  in  the 
papilUe  of  the  vaginal  mucous  membrane. 

The  s}imptoms  are  irregular  htemorrhages  ;  mucous  discharge,  often 
putrid;  pain;  disturbance  of  the  bladder;  a  sense  of  bearing  down  and 
wasting. 

For  diagnosis  a  piece  of  the  diseased  structure  should  be  excised  and 
examined  with  the  microscope. 

The  prognosis  is  exceedingly  bad ;  the  disease  returns  in  spite  of 
operation.  Schuchhardt  gives  one  case  in  which  the  patient  remained 
free  from  its  return  for  two  years. 

The  treatment  consists  in  the  earliest  possible  removal  of  the  disease. 

Foreign  Bodies  in  the  Vagina,  —  A  great  number  of  foreign  bodies 


392  SYSTEM  OF  GYNAECOLOGY 

have  been  found  in  the  vagina  —  glasses,  cups,  candles,  reels,  and  the 
like,  which  have  been  introduced  for  sexual  gratification  ;  also  hair-pins, 
sponges,  tampons,  and  pessaries  "which  have  been  worn  by  patients  for 
ten  years  and  upwards,  and  have  been  completely  forgotten.  Entozoa 
may  be  introduced  from  the  bowel;  the  ascaris  lumbricoides,  the 
oxyuris  vermicularis,  and  the  pulex  irritans  have  been  found,  and  in  one 
case  a  grasshopper.  Large  foreign  bodies  compel  the  patients  at  once  to 
seek  medical  aid;  smaller  ones  remain  to  produce  vaginitis  with 
purulent  offensive  discharge  mixed  with  blood,  saprophytes,  and  other 
pathological  micro-organisms,  which  cause  a  foetid  irritating  discharge 
resembling  that  of  cancer.  Not  infrequently  stenosis  occurs  in  the 
vagina,  just  below  the  foreign  body,  with  almost  complete  occlusion  of  the 
vagina ;  the  diagnosis  can  then  be  made  by  rectal  examination  only. 
The  removal  of  the  body  is  not  always  a  simple  matter ;  but  it  is  an 
absolute  necessity,  since  its  retention  might  cause  death  from  putrid 
peritonitis.  The  first  step  is  the  antiseptic  douche ;  the  second  is  to 
dilate  the  stricture ;  the  third  is  to  remove  the  foreign  body.  Occasion- 
ally it  is  necessary  to  divide  the  recto-vaginal  septum,  which,  after  the 
removal  of  the  foreign  body,  should  be  followed  by  immediate  reunion. 
The  cavity  left  should  be  thoroughly  disinfected  and  plugged  with 
gauze. 

W.  Smyly. 


REFERENCES 

Diseases  of  the  External  Genital  Organs  — Vulvitis: —  1.  J.  M.  Duncan.  Lancet, 
1877.  March  .3.-2.  Med.  Times  and  Gaz.  Feb.  3,  1880,  p.  199.— 3.  C.  v.  Braun. 
Wien.  med.  Wochensch.  1878.-4.  Kinder  Wood.  Med.-Chii-.  Ti-ans.  vol.  vii.  — 5. 
Parrot.  Rev.  de  med.  p.  177,  1881.  — 6.  Herman.  Obstet.  Trans.  1883.-7. 
Priestley.  Obstet.  Trans.  1884.-8.  Tarnowsky.  Ctbl.f.  Chir.  p.  354,  1887.-9.  E. 
Luther.  Vol.  klin.  Vort.  N.  F.  82,  83,  1893. —  10.  Wertheim.  Verh.  der  Dtsch. 
Ges.  f.  Gya.  §340,1891.-11.  Sanger.  Verh.  d.  Dtsch.  Gcs.  f.  Gyh.  §301,1892.— 
12.  Schaffer.  Verh.  d.  Schles.  Ges.  /.  Vaterlandkult.  Feb.  1894.-13.  J.  Veit. 
Zelt.  f.  Gebh.  v.  Gya.  Bd.  xxviii.  1894.  — 14.  G.  Klein.  Monats.  f.  Geb.  u.  Gyn.  Jan. 
1895.  Tumours;  —  (Elephantiasis):  15.  M'Clintock.  Dub.  Journ.  xxiii.  18()2.  — 10. 
Playkair.  Trans.  ObsUU.  Hoc.  xix.  p.  184.-17.  Peters  aud  Klebs.  Prag.  Vier- 
telj.,  124,  §  09,  1874.  (Lupus):  18  West.  JJis.  of  Wo7n.  p.  822,  1870.  — 19.  J. 
M.  Du.NCAN.  Jidin.  Med.  Journ.  Dec.  1802. — 20.  HUter.  Dtsch.  Zeitsch.  f.  Chir.  iv. 
p.  .508,  1874.-21.  Thompson.  Lancet,  1892. — 22.  Hkgar.  Gen.  tuberculosa  des 
Wfdbfis,  1887.  (Malignant):  23.  Eberhardt.  IHs.  Wurzburg,  1885.-24.  Kijstner. 
Z".it.  f.  Gebh.  u.  Gyn.  vii.  §  70,  1881.  — 25.  Schroedkr.  Zeit.f.  Geb.  u.  Gyn.  iii.  423, 
1H78.  —  20.  Prkscott  Hewitt.  Lancet,  March  10,  1801.  —  27.  Robb.  Johns  Hopkins 
Hosp.  Rep.  ii.  227,  1890.-28.  Thomas.  N.  Y.  Jour.  xxxi.  490,  1880.  (Fibro- 
myoma) :  29.  Klob.  Path.  Anat.  d.  weibl.  Sexualorrjane,  p.  4.59, 1804.  —  30.  M'Clintock. 
Dub.  Jour.  vol.  iv.  18f;2.  —  31.  A.  R.  Simpson.  Kd.  Mod.  Jour.  1878.-32.  J.  M. 
Duncan.  Med.  Times  and  Gaz.  Jan.  24,  1880.  (Lipoma)  :  33.  Stucgklio.  Zeit.  f. 
Chir.  n.  Geb.  Bd.  ix.  ]).  24.'5,  1850.-34.  Bruntzkl.  CM.  f.  Gyn.  p.  020,  1882. 
(Enchondroma)  :  .''>5.  Sciinkkvoot.  Ver.  van  het  Geu.oolschap  ter  Bcvordering  d. 
Geneesen  IlecUcu.nile  te  Amstenlam.,  ii.  1,  p.  07,  1885.  —  30.  Bekjkl.  Der  Kra7ik.  des 
weib.  Gesc'i.  lid.  ii.  p.  728.  (Neuroma):  .37.  Simpson.  Med.  Times,  Oct.  1859. — .38. 
Kennedy.  Mfd.  Press,  and  Clr.  June  7,  1874.  (Angioma):  ;'.9.  Sanger.  Ctbl. 
r.  Gyn.  p.  125,  1882.  (Cystoma):  40.  Wertii.  (U.bl.  f.  Gyn.  j).  512,  1878.-41. 
Gala'bin.  Obstet.  Trans,  p.  .54,  1884.-42.  WUIshire  Obstet.  Trans.  Lond.  1881. 
Pruritus  Vulvae:  — 43.  L.  Mayer.     Mon.  f.  Geb.  July  1862.— 44.  Edis.     Ii.  M.  J.  ,hx\\. 


DISPLACEMENTS   OF  THE    UTERUS  393 

11,  18(i8.  —  45.  ScHROEDER.  Cthl.  f.  Gyn.  p.  805,  1884.  Kraurosis  Vulvae:  — 46. 
Breisky.  Zeit.  f.  Heilk.  vi.  69,  1885. —47.  Orthmann.  Zcit.  f.  Geb.  u.  Gyn.  xix. 
§283,  1890.  Vaginitis: — 48.  Doderlein.  Das  Scheidensekret.  Leipzifj,  1892. — 49.  C. 
RuuE.  Zcit.  f.  Gebur.u.  Gyn.  Bd.  iv.  1879. — 50.  Efpinger.  Frag.  Zeit.  f.  Tllk.  iii. 
153. — 51.  E.  Frankel.  Virch.  Arch.  xcix.  p.  2.")1,  1883.  —  52.  Chiari.  Frar/.  Zeit. 
f.  Hlk.  V).  §  81,  1885.-53.  Birch.  Hlrsch.  Lehrbuch,  ii.  p.  7i)4,  1887.— 54.  Kummel. 
Virch.  Arch.  cxiv.  p.  429,  1888.  —  55.  V.  Herff.  Folk.  Sam.  cxxxvii.  1895. — 56. 
WiNKEL.  Arch.  f.  Gyn.  Bd.  ii.  p.  383,  1871.  Vaginismus: — 57.  J.  M.  Duncan. 
Clin.  Led.  on  Dis.  of  W.  p.  142,  1883. —58.  M.  Sims.  Obstet.  Trans,  vol.  iii.  p.  350. 
1862.  — 59.  J.  Y.  Simpson.  Dis.  of  Worn.  p.  284,  1872.-60.  Budin.  Frogres  Med. 
Paris,  ix.  1887.  Vaginal  New  Growths: — 61.  O.  Hemming.  Edin.  Med.  and  ^urg. 
Journ. — 62.  G.  Veit.  Krank.  desiveibl.  Gesch.  ISiJl. — 63.  Winkel.  Lehrb.  Frauenk. 
§112,1890.-64.  Klebs.  Path.  Anat.  1876.-65.  Hall  Davis.  Trans.  Obstet.  Soc. 
1867. — 66.  V.  Preuschen.  Virch.  Arch.  Bd.  Ixx.  1877. — 67.  Cullingworth.  Obstet. 
Journ.  of  Gt.  Britain  and  Ireland,  Oct.  1879.  —  68.  J.  M.  Duncan.  3Ied.  Times  aiid 
Gaz.  1880. —69.  M'Clintock.  Clin.  Memoirs  of  Dis.  of  Worn. — 70.  Paget.  Led. 
on  Surg.  Fath.  —  71.  Barnes.  Obstet.  Trans,  vol.  xiv.  p.  309. — 72.  Hegar.  Geniial- 
tuberculosa  des  Vi^eib.  1887.— 73.  Strassman.  Ctbl.  f.  &V«- §  825,  1891.  — 74.  B.aj>ly. 
Med.  and  Surg.  Reporter,  xlii.  p.  199.  —  75.  Klein.  Zeit.  f.  Geb.  u.  Gyn.  xviii.  §  82, 
1890.  Foreign  Bodies  : — 76.  Diefenbach.  "Fremdkorper  in  d.  weibl.  Gen.  u.  Harn- 
blase,"  Dis.  Berlin,  1890.— 77.  Klebs.  Handb.  d.  path.  Anat.  Bd.  i.  p.  976.— 78. 
Pearse.  Brit.  Med.  Journ.  28th  June  1873.  —  79.  Carter.  Obstet.  Trans,  p.  34, 
1880. 

W.    S. 


DISPLACEMENTS   OF   THE   UTEEUS 

Even  in  perfectly  normal  conditions  the  uterus  is  liable  to  vary  greatly 
in  its  relations  to  the  pelvic  cavity  in  which  it  lies.  These  relations 
are  modified  by  its  own  functional  activities,  as  well  as  by  the  distension 
and  evacuation  of  the  adjacent  viscera.  We  may  consider  it  as  placed 
in  the  pelvis :  (A)  as  regards  its  Level,  so  that  the  fundus  corresponds 
more  or  less  to  the  plane  of  the  brim,  and  the  os  externum  points  to 
the  coccyx  in  the  plane  of  the  ischial  spines  ;  (B)  as  regards  its  Position, 
so  that  it  lies  nearly  midway  between  the  symphysis  pubis  and  sacrum, 
and  between  the  two  sides  of  the  pelvis ;  and  (G)  as  regards  its  Direction, 
so  that  its  axis  corresponds  more  or  less  to  the  axis  of  the  pelvis.  So 
we  may  find  it  in  moderate  degrees  of  distension  of  the  bladder  and 
rectum.  Let  these  organs,  however,  be  fully  distended,  and  the  uterus 
Avill  be  raised  above  the  level  which  we  have  assigned  to  it.  Let  the 
bladder  alone  be  distended,  and  the  uterus  Avill  be  carried  back  beyond 
the  middle  line  of  the  pelvis.  Let  the  bladder  be  emptied,  and  the 
uterus  will  fall  forward  so  that  its  fundus  comes  close  to  the  symphvsis 
pubis.  It  is  in  this  position  that  it  is  most  frequently  found  on  bimanual 
examination. 

With  this  wide  range  of  physiological  mobility  it  keeps  its  place  by 
virtue  of :  (i.)  the  insertion  of  the  supravaginal  portion  of  the  cervix  in 
the  upper  end  of  the  vagina,  where  it  rests  upon  the  tip  of  the  sacrum 
and  coccyx  in  the  pelvic  floor ;  (ii.)  the  action  of  the  utero-sacral  liga- 
ments, which  keep  the  isthmus  in  its  proper  relation  to  the  upper  part  of 


394  SYSTEM   OF  GYNAECOLOGY 

the  hollow  of  the  sacrum ;  (iii.)  the  utero-vesicle  ligaments,  which  main- 
tain its  relation  to  the  bladder  and  symphj^sis  pubis ;  (iv.)  the  broad ' 
ligaments  on  each  side,  which  especially  regulate  its  lateral  movements; 
and  (v.)  the  round  ligaments,  which  keep  the  fundus  directed  upward  and 
forward  towards  the  inguinal  canals.  When  it  fails  to  retain  its  equi- 
librium, either  in  the  way  of  excess  of  movement  beyond  its  normal 
range,  or  of  losing  the  power  to  recover  its  normal  relations,  its  displace- 
ments become  pathological,  and  give  rise  to  troubles  that  lead  the  patient 
to  seek  for  medical  advice. 

In  a  large  proportion  of  cases  the  displacement  will  be  found  to  be 
not  simple,  but  compound.  Thus,  Avhere  there  is  a  downward  deviation 
from  the  ordinary  level,  and  the  uterus  is  prolapsed,  there  is  usually  also 
a  loss  of  its  normal  direction,  and  the  uterus  is  retroverted.  But  it  is 
the  downward  displacement  that  is  the  most  important  element  in  the 
case,  and  which  most  urgently  calls  for  rectification.  Again,  in  many 
cases  an  anteflexed  uterus  may  be  found  lying  close  to  the  hollow  of  the 
sacrum  in  a  state  of  retroposition ;  and  it  may  require  careful  analysis  of 
the  conditions  before  the  practitioner  can  decide  which  of  the  two  devia- 
tions— the  deviation  in  direction  or  in  position  —  is  the  more  chargeable 
with  the  patient's  sufferings.  We  will  study,  however,  the  different 
displacements  in  succession  and  consider  :  — . 


A.    Deviations  from  the  Normal  Level 

The  uterus  may  be  found  moved  beyond  the  planes  of  the  pelvis 
within  Avliich  it  normally  ranges  either  Upwards  or  Downwards. 

I.  Ascent  of  the  Uterus.  —  In  the  elevations  or  upward  displace- 
ments of  the  uterus,  the  organ  is  lifted  off  the  pelvic  floor,  and  the  fundus 
rises  above  the  jjelvic  brim  so  as  to  be  accommodated  to  a  greater  or  less 
extent  in  the  abdominal  cavity.  The  gravid  uterus,  say  from  the  third 
month  onwards,  grows  gradually  and  at  a  steady  rate  higher  and  higher 
in  the  abdomen.  So  when  the  unimpregnated  uterus  becomes  the  seat 
of  a  large  myoma,  it  may  have  become  largely  an  abdominal  organ  before 
it  comes  under  observation.  When  a  tubal  gestation  goes  on  develop- 
ing beyond  the  early  months;  when  an  ovarian  or  parovarian  tumour 
grows  down  into  the  broad  ligament  or  becomes  fixed  behind  the  uterus; 
when  an  effusion  or  extravasation  is  encapsuled  in  the  pouch  of  Douglas; 
or  a  tumour  grows  in  the  rectal  wall ;  —  in  all  these  and  similar  cases  the 
uterus  may  be  lifted  or  pushed  upwards :  and  even  in  some  peritonitic 
cases  the  fundus  may  have  acquired  adhesions  which  drag  it  towards  the 
abdomen.  The  ascent  of  the  uterus  under  such  circumstances,  however,  is 
only  a  bye-phenomenon.  It  may  be  of  vital  importance  to  recognise  the 
abnonnal  ])Osition,  and  our  successful  treatment  of  the  patient  may 
depend  on  its  deif.ction  ;  but  elevation  of  the  uterus  does  not  present 
itself  to  us  as  an  isolated  occurrence,  and  the  symptoms  associated  with 
it  are  subsidiary  to  those  (jf  the  condition  which  brought  it  about.     It 


DISPLACEMENTS   OF   THE    UTERUS  395 

is  quite  otherwise  with  the  downward  displacements,  which  we  now 
proceed  to  consider. 

II.  Descent  of  the  Uterus.  —  Prolapsus  or  procidentia  uteri — fall- 
ing down  or  protrusion  of  the  womb  —  are  names  that  have  been  used  to 
express  the  downward  displacement  of  the  uterus,  which  leads  to  its  escape 
from  the  pelvic  cavity  till  it  comes  to  lie  externally  to  the  pudenda.  It 
must  be  recognised  at  once  that  here  the  dislocation  of  the  uterus  is  not 
an  isolated  phenomenon.  As  the  organ  sinks  in  the  pelvis  it  drags  with  it 
its  adnexa,  the  Fallopian  tubes  and  ovaries :  its  depression  is  followed  by 
depression  of  the  superincumbent  coils  of  the  intestines ;  and,  even  if 
in  the  early  stage  of  the  process  the  vaginal  walls  with  the  bladder  anil 
rectum  may  have  retained  somewhat  of  their  normal  position,  in  the 
more  advanced  stages  these  have  all  moved  downwards  to  such  an  extent 
that  the  vagina  has  become  completely  inverted :  so  that  we  have  to  do 
with  a  hernial  process,  the  pelvic  contents  escaping  through  the  obliq\ie 
fissure  in  the  pelvic  floor,  which  we  think  of  as  the  vaginal  canal,  until 
we  have  a  sac,  the  covering  of  which  is  formed  by  the  inverted  vaginal 
walls,  and  the  contents  of  which  consist  of  the  body  of  the  uterus  and 
the  adjacent  viscera.  The  displacement  may  begin  at  the  upper,  uterine 
extremity  of  the  fissure,  or  at  the  lower,  pudendal  extremity ;  or  the 
favouring  conditions  may  operate  simultaneously  throughout  the  whole 
pelvic  floor.  But  in  any  case  the  displacement  of  the  uterus  is  the 
central  element  in  the  disturbance ;  its  functional  troubles  are  prom- 
inent among  the  attendant  symptoms ;  and  the  treatment  must  have 
regard  to  its  reposition  and  its  retention  in  its  proper  place. 

The  displacement  may  be  met  with  at  different  stages,  so  that  a 
distinction  has  been  drawn  between  the  different  degrees  of  descent. 

Degrees  of  Descent. — i.  In  the  simplest  cases  the  uterus  has  only 
sunk  downwards  to  a  slight  degree  from  its  ordinary  level,  the  fundus 
lying  distinctly  below  the  brim  of  the  pelvis,  and  the  os  low  on  the  pelvic 
floor ;  but  it  retains  its  ordinary  position  in  the  middle  of  the  pelvis,  and 
the  fundus  has  its  ordinary  anterior  inclination,  ii.  In  a  second  group 
of  cases,  where  the  prolapse  is  still  incomplete,  the  uterus  has  sunk  still 
lower,  with  the  os  resting  on  the  anterior  margin  of  the  perineum,  or  ap- 
pearing at  the  pudendal  fissure,  and  the  fundus  is  found  at  a  varying 
height  according  to  the  size  of  the  organ.  In  this  variety  the  uterus  has 
undergone  a  change  in  the  direction  of  its  axis,  and  has  fallen  backwards 
towards  the  hollow  of  the  sacrum,  so  that  it  is  not  only  in  a  state  of 
prolapse,  but  at  the  same  time  of  retroversion  or  retroflexion,  iii.  In 
cases  of  complete  descent  the  whole  organ  has  sunk  so  low  that  it 
projects  Avithin  the  inverted  vagina  completely  beyond  the  pudendal 
orifice ;  and  in  this  situation  the  body  is  iisually  found  retroverted,  though 
in  rare  cases  the  fundus  may  be  directed  upwards  or  forwards.  It 
has  sometimes  been  proposed  to  distinguish  the  varying  degrees  of  de- 
scent by  speaking  of  the  incomplete  varieties  as  cases  of  prolapsus,  and 
the  complete  variety  as  procidentia  uteri.  The  names,  however,  are  not 
distinctive ;  and  whether  we  call  the  descent  prolapse  or  procidence,  we 


396  SYSTEM   OF  GYNECOLOGY 

must  distinguisli  between  the  cases  where  the  uterus  is  still  within  the 
vaginal  cavity,  and  those  w^iere  it  is  entirely  extruded,  by  speaking  of 
the  former  as  incomplete  and  the  latter  as  complete  prolapse.  In  the 
case  of  incomplete  prolapse,  we  have  the  two  sub-varieties :  (a)  incom- 
plete prolapse  of  normally  inclined  uterus;  and  (6)  incomplete  prolapse 
of  retroverted  uterus.  In  the  case  of  complete  prolapse  the  direction  of 
the  uterus  is  of  minor  moment. 

Pathological  Anatomy.  —  If  we  look  more  carefully  at  the  structures 
protruding  through  the  vulva,  we  shall  find  we  have  to  do  with  different 
elements  of  the  pelvic  contents  in  different  cases.  In  all  the  cases  the 
vaginal  walls  have  become  dislocated,  but  as  regards  other  viscera  we 
find  in  some  — 

i.  Chiefly  displacement  of  uterus.  —  The  tumour  projecting  through 
the  vulva  is  covered  completely  with  the  inverted  Avails  of  the  vagina, 
which  have  lost  their  rugosities  and  present  a  smooth  appearance.  The 
OS  uteri  may  be  seen  at  the  lower  anterior  part,  where  the  cervix  barely 
projects  beyond  the  general  surface  of  the  tumour ;  and  through  the 
walls,  the  body  of  the  uterus  with  its  adnexa,  and  occasionally  some 
intestinal  coils,  can  be  felt  occupying  the  hernial  sac. 

ii.  Chiefly  displacement  of  bladder.  —  Sometimes  the  projecting  stru.ct- 
ure  is  constituted  mainly  by  the  descent  of  the  anterior  wall  of  the 
vagina,  carrying  with  it  the  back  wall  of  the  bladder.  The  case  is  one  of 
cystocele.  In  this  condition  the  uterus  may  be  only  in  the  first  stage 
of  incomplete  descent,  and  remain  functionally  active.  If  the  uterus 
become  gravid  the  cystocele  may  become  aggravated,  and  be  a  source  of 
trouble  during  pregnancy  and  labour,  whilst  the  uterine  displacement  is 
for  the  time  undone.  This  prolapse  of  the  anterior  vaginal  wall,  how- 
ever, is  more  apt  to  become  associated  Avith  hypertrophic  changes  in  the 
cervix  uteri  Avhich  lead  to  more  complete  prolapse  of  the  whole  organ. 

iii.  Chiefly  displacement  of  rectum. — In  rarer  instances  it  is  the  back 
wall  of  the  vagina  that  projects  through  the  vulva.  The  case  is  one  of 
rectocele,  so-called,  or  proctocele. 

iv.  Cystocele  loith  hypertrophy  of  intermediate  portion  of  cervix  uteri. 
—  The  circumstance  that  the  vaginal  mucosa  lays  hold  of  the  cervix  low 
down  in  front  at  about  one-third  of  an  inch  from  the  anterior  lip,  whilst 
behind  it  passes  up  to  within  about  ono-tliii'd  of  an  inch  from  the  isthmus, 
has  led  to  the  convenient  distinction  of  the  cervix  into  the  three  seg- 
ments. Below  we  have  the  vaginal  or  infravaginal  portion,  lying 
entirely  free  in  the  vaginal  cavity  behnv  the  level  of  the  anterior  for- 
nix ;  above  we  have  the  supravaginal  portion  embraced  by  parametrium 
and  lying  entirely  above  the  level  of  the  posterior  foi-nix ;  between 
these  is  the  intermediate  portion  lying  above  the  level  of  the  anterior, 
and  below  the  level  of  the  posterior  fornix.  On  its  posterior  aspect 
this  intermediate  portion  lies  free  in  the  vagina;  its  anterior  surface 
lies  above  the  vaginal  reflection,  and  is  in  contact  with  the  areolar 
tissue  which  separates  it  from  the  bladder  wall.  This  intermediate 
portion  undergoes  a  remarkable  degree  of  hypertrophy  and  elongation  in 


DISPLACEMENTS   OF   THE    UTERUS  397 

cases  where  the  anterior  wall  of  the  vagina  has  been  displaced.  The 
vesico-vaginal  septum  that  has  been  exposed  through  the  vulva  becomes 
congested  and  thickened,  and  is  the  seat  of  a  hyperplasy  that  extends  to 
the  portion  of  the  cervix  with  which  it  is  in  intimate  vascular  relations. 

V.  Cystocele  and  Proctocele,  tvUh  hypertrophy  of  the  whole  siiprcv- 
vagincd  portion.  —  In  many  cases  where  the  cystocele  alone  exists  in  a 
marked  degree,  the  hypertrophy  may  affect  the  whole  supravaginal 
portion  of  the  cervix.  Such  a  hypertrophy  is  more  certain  to  be  pro- 
duced when  the  posterior  as  well  as  the  anterior  vaginal  wall  has  escaped 
through  the  vulva.  In  such  a  case  the  protruded  mass  has  a  large  seg- 
ment of  the  bladder  in  front  and  a  rectal  pouch  behind ;  and  is  felt  to 
contain  only  the  elongated  cervix  and  isthmus  of  the  uterus,  whilst  the 
fundus  and  its  adnexa  are  still  within  the  pelvic  cavity. 

Causes  of  Prolapsus  Uteri.  — We  have  seen  that  the  uterus  maintains 
its  normal  level  by  virtue  of  a  balance  between  the  structures  that  sustain 
it  and  the  forces  that  tend  to  depress  it.  We  must  look,  therefore,  for 
the  causes  of  its  permanent  descent  either,  on  the  one  hand,  to  conditions 
that  weaken  its  supports,  or  on  the  other  to  conditions  that  increase  the 
strain  upon  them.  These  conditions  are  (a)  Passive,  and  (b)  Active.  Fre- 
quently enough  these  conditions  are  simultaneously  operative  in  both 
directions. 

(a)  Passive  causes.  —  These  are  to  be  found  in  loss  of  retentive  power 
of  the  uterine  supports,  and  foremost  among  the  defects  that  lead  to 
descent  of  the  uterus  we  must  place  ;  — 

i.  Faults  in  the  perineum.  —  The  integrity  of  the  perineum  may  be 
seriously  impaired,  and  yet  the  uterus  maintain  its  normal  place.  The 
whole  of  the  structures  between  the  lower  third  of  the  vagina  and  the 
rectum  may  be  found  lacerated  to  such  an  extent  that  the  patient  is 
unable  to  control  the  action  of  the  bowels,  and  comes  to  seek  relief 
because  of  this  trouble.  In  such  a  case  the  uterus  may  be  found  at  its 
normal  level,  the  other  sustaining  structures  being  of  sufficient  strength 
and  tonicity  to  maintain  it  in  place ;  or  inflammatory  or  cicatricial 
changes  may  have  impaired  its  mobility.  As  a  rule,  however,  damage  of 
the  perineum  or  perineal  body  is  a  prime  element  in  the  weakening  of  the 
pelvic  floor  that  eventuates  in  herniation  of  the  pelvic  contents.  This 
damage  is  usually  inflicted  during  labour,  and  may  take  the  form  either 
(a)  of  laceration  beginning  at  the  fourchette,  or  on  the  mucous  surface,  or 
even  on  the  cutaneous  surface,  and  running  more  or  less  deeply  through  all 
the  tissues  to  or  into  the  anal  and  rectal  canal ;  or  (^)  of  diastasis  of  the 
muscidar  and  fascial  tissues  that  meet  in  the  perineal  body,  and  lie 
between  the  mucous  membrane  and  the  skin.  In  the  latter  case  no 
cicatrix  is  to  be  seen  behind  the  vaginal  orifice.  The  mucous  lining 
and  the  skin  covering  of  the  perineum  have  been  dilated  without  being 
fissured,  and  the  structures  seem  to  be  entire  ;  but  when  the  perineum  is 
grasped  between  the  finger  and  thumb,  or  is  stretched  on  two  fingers 
introduced  into  the  vagina,  it  is  felt  to  be  thin  and  relaxed,  and  incapable 
of  offering  any  effective  resistance  to  the  pressure  brought  to  bear  on  it 


39S  SYSTEM   OF  GYNECOLOGY 

from  above.  "Where  the  perineum  has  been  thus  torn  or  strained,  so  that  it 
ceases  to  afford  adequate  support  to  the  superjacent  structures,  the  first 
stage  of  a  displacement  is  seen  in  the  projection  of  the  anterior  vaginal 
wall  through  the  patulous  orifice  ;  and  where  other  causes  are  in  operation 
tending  to  a  descent  of  the  uterus,  the  displacement  comes  about  the 
more  easily  and  rapidly  from  the  absence  of  the  resistance  offered  to  it 
by  the  healthy  perineum. 

ii.  Faults  in  the  vaginal  walls.  —  We  have  seen  that  it  is  through  the 
vaginal  canal  that  the  uterus  becomes  herniated.  It  is  obvious  that  the 
varying  condition  of  the  vaginal  walls  will  modify  the  proclivity  to  the 
uterine  descent.  In  the  cases  where  the  uterus  keeps  its  place,  notwith- 
standing that  the  perineum  is  deeply  fissured,  the  anterior  vaginal  wall 
and  the  posterior  wall  above  the  seat  of  laceration  are  usually  found  to 
be  healthy.  The  rugae  are  well  preserved  ;  the  submucous  muscular  and 
areolar  tissues  have  retained  their  tonicity ;  and  freedom  from  all  the 
leucorrhoeal  discharges  associated  Avith  colpitis  allows  the  walls  to  retain 
their  normal  degree  of  apposition.  Where,  on  the  other  hand,  the 
vaginal  walls  have  become  so  distended  as  to  have  lost  something  of  their 
tonicity,  and  where,  in  addition,  the  surfaces  are  bathed  with  a  discharge 
due  to  inflammatory  and  congestive  processes,  the  walls  readily  become 
separated,  and  the  inversion  of  the  canal  is  facilitated  either  from  below 
or  above.  That  it  more  frequently  begins  from  below  is  due  to  the 
frec^uent  initiation  of  the  mischief  by  the  perineal  defect  which  leads  to 
exposure  of  the  lower  part  of  the  anterior  wall.  Every  mucous  membrane 
subjected  to  unusual  exposure  is  apt  to  become  the  seat  of  inflammatory 
changes,  as  may  be  seen  in  ectropion  of  the  palpebral  conjunctiva,  or  of 
the  cervical  endometrium  ;  hence  the  perineal  laceration  leading  to 
exposure  of  the  anterior  vaginal  wall,  is  usually  attended  with  chronic 
inflammatory  changes,  that  lead  to  general  colpitis  with  free  discharge 
and  thickening  of  the  tissues  that  favour  the  production,  first  of  cysto- 
cele  and  then  of  a  more  complete  prolapse. 

iii.  Faults  in  uterine  ligaments.  —  In  some  instances  we  trace  the 
descent  of  the  uterus,  not  so  much  to  loss  of  power  in  the  structures  that 
support  it  from  below,  as  to  inefficiency  of  the  structures  that  should 
retain  it  above.  It  is  the  relaxation  of  all  its  ligaments,  utero-sacral 
and  utero-vesical,  broad  and  round,  subsisting  for  some  time  after  jiarturi- 
tion,  that  facilitates  the  sinking  down  of  the  uterus  which  is  so  apt  to  be 
initiated  during  the  puerperium.  When  these  ligaments  remain  per- 
manently relaxed  and  strained  a  more  decided  and  pernument  descent  of 
the  uterus  ensues. 

iv.  Faults  in  the  cellular  tissues.  —  In  the  areolar  tissues  surrounding 
the  pelvic  organs,  and  filling  in  the  interspaces  between  the  layers  of 
fascia  in  the  different  muscular  planes,  there  is  found  in  healthy  women 
a  considerable  amount  of  fat.  When  absorption  of  this  adi])Ose  deposit 
takes  place,  as  in  i)atients  who  are  the  subjects  of  wasting  disease,  and  in 
some  women  at  the  cliinactoric  period,  a  tendency  to  downward  displace- 
ment of   the   uterus   and    vaginal   walls   is   distinctly  traceable.     This 


DISPLACEMENTS    OE   THE    UTERUS  399 

prolapse  may  be  partly  due  to  weakening  of  the  ligaments,  which  is  not 
unlikely  to  be  present  under  such  circumstances,  but  the  absence  of  the 
normal  fatty  padding  of  the  pelvis  contributes  in  a  notable  degree  to  the 
result. 

V.  Faults  in  the  pelvis.  —  AVe  can  understand  that  the  contraction  of 
the  brim  and  expansion  of  the  outlet,  characteristic  of  the  rickety  pelvis, 
should  favour  the  descent  of  the  uterus ;  so  that  we  sometimes  find  pro- 
lapsus uteri  in  virgins  associated  with  this  form  of  pelvis.  In  a  secondary 
sense  this,  and  other  varieties  of  malformation,  become  causes  of  prolapsus 
in  the  damage  that  may  be  done  during  labour  by  the  operative  pro- 
cedures which  they  render  necessary.  Besides,  these  changes  in  con- 
figuration are  occasionally  associated  with  changes  in  the  inclination  of 
the  pelvis ;  and  whenever  the  inclination  of  the  pelvis  is  continuously 
disturbed,  and  the  plane  of  the  brim,  instead  of  meeting  the  horizon  at 
an  angle  of  about  hi)°,  becomes  more  or  less  parallel  to  it,  downward 
displacements  of  the  uterus  are  favoured.  Such  change  from  the  normal 
inclination  occurs  in  elderly  women  in  whom  the  anterior  curve  of  the 
lumbar  vertebrae  is  lost,  and  in  others  whose  avocations  keep  them  for 
long  periods  of  time  in  such  attitudes  that  the  promontory  of  the  sacrum, 
instead  of  being  four  inches  above  the  level  of  the  upper  margin  of  the 
pubic  symphysis,  is  nearly  in  the  same  horizontal  plane. 

(IS)  Active  causes.  —  Among  the  conditions  that  operate  more  directly 
in  producing  prolapsus  uteri  we  note  :  — 

i.  Enlargements  of  the  uterus  itself. — In  the  early  weeks  of  pregnancy, 
when  the  uterus  begins  to  grow,  it  sinks  slightly,  so  that  the  os  is  found 
at  a  somewhat  lower  level  than  in  the  case  of  the  non-gravid  organ. 
During  the  puerperium  the  descent  of  the  uterus,  which  is  rendered  possi- 
ble by  the  relaxation  of  its  ligaments,  is  promoted  by  the  increase  in  its 
own  weight,  which  persists  until  its  involution  is  complete.  When  the 
involution  is  interrupted,  and  the  uterus  remains  enlarged  in  conse- 
quence of  the  subinvolution,  or  when  it  is  hypertrophied  as  a  result 
of  chronic  metritis,  or  from  the  development  of  neoplasms  in  its  walls, 
the  increase  in  weight  of  the  organ  is  among  the  factors  that  tend  to  its 
depression.  For  though  the  h3-pertrophies  of  the  uterus  may  sometimes 
be  a  result  of  congestive  processes  due  to  its  displacement,  in  many  cases 
the  hypertrophy  initiates  the  descent,  and  in  any  case  it  favours  it. 

ii.  Distension  of  neighbouring  organs.  —  Habitual  over-distension  of 
the  bladder  necessarily  causes  undue  pressure  on  the  pelvic  floor  and 
undue  strain  on  the  ligaments  of  the  uterus  with  wliich  the  bladder  is  in 
such  intimate  relation  ;  it  must  be  regarded,  therefore,  as  among  the 
causes  of  uterine  displacement.  In  a  less  degree  habitual  constipation 
has  a  similar  effect. 

iii.  Increase  of  supra-pelvic  pressure.  —  Of  the  causes  that  work 
actively  towards  the  production  of  prolapsus  uteri,  however,  the  greatest 
importance  is  to  be  attached  to  those  which  produce  their  effect  by 
increasing  the  pressure  that  is  more  or  less  continuously  exerted  on  the 
pelvic  contents.     This  supra-pelvic  pressure  is  increased  in  cases  of  (a) 


40O  SYSTEM  OF  GYNECOLOGY 

Relaxation  of  the  abdominal  walls.  Such  relaxation  is  especially  apt  to 
occur  in  multiparous  women,  especially  where  the  walls  have  been  over- 
stretched from  the  presence  of  unusually  large  children,  or  twins,  or 
hydramnios.  It  may  also  be  found  in  women  who  have  been  subjected 
to  laparotomy  for  a  large  ovarian  tumour.  The  abdominal  walls  are  soft 
and  thin,  the  muscular  layers  have  lost  their  tonicity,  and  the  so-called 
"  retentive  power  "  of  the  abdomen  is  impaired.  The  abdominal  viscera, 
instead  of  being  retained  in  their  normal  relations,  tend  to  sink  down- 
wards ;  and  so  there  comes  about  a  continuous  pressure  on  the  pelvic 
viscera,  which  promotes  herniation  through  the  pelvic  floor.  (/3)  In  some 
cases  the  supra-pelvic  pressure  is  increased  from  the  presence  of  tumours 
in  the  abdominal  cavity,  or  of  ascitic  accumulation  in  the  peritoneal 
sac.  More  frequently  it  results  from  (y)  Improper  kinds  of  dress  ;  as 
for  example,  where  the  waist  is  kept  constricted  by  corsets  too  tightly 
laced,  or  heavy  clothing  is  supported  on  bands  round  the  abdomen. 
(3)  When  a  woman  is  under  the  necessity  of  making  strong  or  long- 
continued  muscular  exertions,  the  pressure  tells  upon  the  pelvic  con- 
tents ;  and  in  cases  where  prolapsus  uteri  is  said  to  have  occurred  sud- 
denly the  displacement  is  usually  attributed  to  some  severe  voluntary 
effort,  or  to  an  accident  attended  with  strong  muscular  effort. 

In  considering  the  causes  of  prolapsus  uteri  we  have  to  remember 
that  the  process  of  descent  is  a  gradual  one.  Cases  are  met  with  from 
time  to  time  where  the  patient  has  become  suddenly  aware  of  the  mis- 
chief, and  she  may  tell  us  that  the  protrusion  was  the  result  of  an  in- 
jury or  strain.  But  when  we  inquire  more  carefully  into  the  history,  we 
recognise  that,  though  the  last  stage  of  the  displacement  came  on  thus 
rapidly,  there  had  been  previous  indications  of  disturbance ;  and  when 
we  make  our  physical  investigation  we  find  traces  of  long-standing  change 
in  the  pelvic  structures. 

We  have  to  keep  in  view,  further,  that  we  have  to  do,  not  with  the 
effect  of  one  of  the  above-named  causes  alone  and  independently,  or 
even  of  one  of  the  groups  of  causes,  but  with  the  combined  influence  of 
several  of  them  acting  continuously  and  for  long  periods.  The  women 
who  are  most  subject  to  this  displacement  belong  to  the  working  classes ; 
and  in  any  individual  suiferer  the  mischief  is  likely  to  have  begun  after  a 
confinement  attended  by  damage  to  the  perineum.  The  patient,  it  may 
be,  got  up  on  the  second  or  third  day,  and  had  to  attend  to  her  child  and 
do  her  househohl  work ;  or  she  may  even  have  been  obliged  to  follow 
some  bread-winning  avocation,  whilst  the  womb  was  still  large  and 
its  ligaments  still  relaxed.  The  passive  conditions  and  the  active 
causes  conjoin  in  such  a  case  to  cause  the  displacement ;  if  they  operate 
month  after  month,  and  year  after  year,  perhaps  with  aggravations  from 
succeeding  pregnancies,  they  inevitably  produce  a  complete  prolapse. 
The  influence  of  any  one  of  the  factors  may  be  slight;  but  it  is 
associated  with  others  which  may  have  arisen  indej^endent.ly ;  and 
their  conjoint  influence  continues  throughout  long  periods.  J  Fence  we 
cannot  learn  much  of  the  produ(;tion  of  i)rolapsus  uteri  by  experiment 


DISPLACEMENTS   OF  THE    UTERUS  401 

on  the  amount  of  force  required  to  pull  the  os  doAvu  to  the  vulva,  and 
to  bring  it  outside  the  orifice. 

Complications.  —  Before  proceeding  to  consider  the  symptoms  and 
diagnosis  of  prolapsus,  we  must  note  that  the  displacement  is  constantly 
complicated  with  morbid  changes  in  the  displaced  structures. 

i.  In  the  uterus.  —  Not  only  is  the  uterus,  that  has  descended  from  its 
normal  level,  apt  to  be  displaced  backwards,  it  is  commonly  also  the 
subject  of  a  marked  degree  of  hypertrophy.  The  hypertrophy  may 
chiefly  affect  the  body  of  the  uterus.  The  organ  may  have  been  from  the 
first  in  the  state  of  subinvolution  that  so  frequently  gives  a  proclivity  to 
displacement ;  or  a  chronic  congestive  metritis  may  have  taken  place 
during  the  course  of  its  descent.  All  the  walls  ai-e  thickened  and 
indurated,  and  the  endometrium  is  expanded  and  vascular ;  until  the 
menopause  sets  in,  a  patient  Avith  a  prolapsed  uterus  is  thus  the  subject 
of  constant  endometritis.  In  other  cases,  and  more  frequently,  the 
inflammatory  process  is  not  confined  to  the  body  of  the  uterus ;  the  cervix 
also  is  hypertrophied.  The  resulting  elongation  of  the  cervix  may  be 
found  affecting  the  supravaginal  and  intermediate  portions,  so  that  the 
canal  is  more  than  double  its  ordinary  length;  whilst  the  anterior  lip 
barely  i:)rojects  beyond  the  level  of  the  anterior  fornix.  This  state  of 
matters  obtains  Avhere  the  mischief  has  begun  with  exposure  of  the 
anterior  vaginal  wall  from  incompetence  of  the  perineum.  In  other 
instances  we  have  to  do  with  a  hypertrophy  of  the  infravaginal  portion 
of  the  cervix.  The  two  lips  of  the  os  are  usually  found  distinctly 
separated  as  a  result  of  Assuring  during  labour,  and  both  lips  may 
be  found  thickened  and  elongated.  If  one  lip  be  predominantly 
affected  it  is  likely  to  be  the  anterior.  This  hypertrophy  of  the 
cervix  is  carefully  to  be  distinguished  from  another  variety  of  elonga- 
tion of  the  infravaginal  portion  of  the  cervix  uteri,  which  may  be 
congenital  in  its  origin,  and  in  which  such  an  elongation  of  the  infra- 
vaginal portion  exists,  that  the  external  orifice  may  appear  at  the  vulva  or 
even  project  bej^ond  it,  whilst  yet  the  fundus  of  the  unaltered  body  of 
the  uterus  retains  its  normal  place  at  the  pelvic  brim.  In  the  different 
forms  of  cervical  hypertrophy  the  lining  membrane  shares  in  the  growth 
and  vascularity,  so  that  Ave  constantly  find  a  catarrhal  endometritis,  both 
cervical  and  corporeal.  The  endocervical  catarrh  is  likely  to  extend 
through  the  ectropic  orifice,  so  that  we  frequently  see  catarrhal  patches 
on  the  external  surface  of  the  lips ;  and  when  the  prolapse  has  existed 
for  some  time  in  a  complete  form,  the  eroded  surfaces  are  usually 
covered  with  a  diphtheroid  pellicle.  It  is  noteworthy  that  the  lids 
of  the  procident  uterus,  so  subject  to  simple  inflammatory  changes, 
very  rarely  become  the  seat  of  cancerous  disease.  Now  and  again  an 
epithelioma  is  found  in  the  protruded  cervix,  usually  in  women  well  past 
the  menopause;  but  procidence  of  the  ragged  os  of  a  multipara  seems  to 
confer  on  it  a  certain  immTxnity  from  malignant  degeneration. 

ii.  In  the  vagina.  —  Whilst  the  herniation  is  still  in  progress,  the 
vaginal  walls  are  in  a  catarrhal  condition  and  covered  with  moisture 


402  SYSTEM  OF  GYNECOLOGY 

Wheu  it  is  complete  the  surfaces  that  have  become  smoothed  and 
deprived  of  their  rugosities  become  perfectly  dry  ;  and  in  cases  of  long- 
standing eversion,  the  investing  epithelium  takes  on  in  places  the  appear- 
ance of  the  epidermis  of  the  skin.  Eroded  surfaces  are  not  infrequently 
found  in  the  neighbourhood  of  the  cervix  uteri  covered,  like  those  on  the 
cervix,  with  a  grayish  shining  pellicle.  Very  rarely  ulcerative  processes 
affect  it  more  deeply,  or  an  epitheliomatous  degeneration  may  occur ;  but 
these  are  more  likely  to  result  from  the  action  of  ill-adjusted  pessaries 
than  from  the  long-continued  displacement. 

iii.  In  the  bladder.  —  Imperfect  evacuations  of  the  distorted  bladder 
are  apt  to  lead  eventually  to  cystitis ;  and  in  the  diverticulum  that 
pouches  through  the  vaginal  orifice  below  the  level  of  the  meatus 
urinarius  concretions  occasionally  form.  I  have  removed  three  vesical 
calculi  from  such  a  displaced  bladder,  complicating  prolapsus  uteri,  which 
had  formed  in  a  woman  from  a  district  where  stone  in  the  bladder  is 
almost  unknown. 

iv.  In  the  rectum.  —  The  rectum  \\\^  be  the  seat  of  irritation  and  of 
undue  lodgment  of  f^cal  matter  where  the  pouch  of  the  rectocele  pro- 
jects distinctly  below  the  anal  aperture.  Sometimes  prolapsus  recti  is 
found  in  a  patient  with  prolapsus  uteri. 

V.  In  the  pelvic  peritoneum.  —  As  the  appendages  of  the  uterus  follow 
it  in  its  displacement,  so  they  are  likely  to  share  in  its  inflammatory 
changes.  The  most  important  of  the  intrapelvic  inflammations,  however, 
to  be  noted  in  connection  with  descent  of  the  uterus,  is  that  which  affects 
the  pelvic  peritoneum.  When  pelvic  peritonitis  is  set  up  in  this  hernial 
sac  it  is  apt  to  lead  to  adhesions  of  the  apposed  surfaces  of  the  viscera  in 
their  distorted  relations,  and  any  attempt  at  reposition  in  such  circum- 
stances may  be  attended  not  only  with  suffering,  but  with  danger  to  the 
I^atient. 

Symptoms.  — The  symptoms  that  arise  are  due  partly  to  the  displace- 
ment, and  partly  to  the  attendant  changes  in  the  uterus  and  adjacent 
organs. 

i.  Disturbance  of  uterine  functions.  —  The  patient  may  have  menor- 
rhagia  due  to  the  endometritis.  She  has  commonly  leucorrhoea  whilst  the 
descent  is  in  progress,  and  this  discharge  lessens  or  disappears  when  the 
prolapsus  is  complete.  Conception  may  occur,  and  the  displacements 
may  prove  troublesome  during  pregnancy  or  labour.  As  a  rule  the  pa- 
tient's reproductive  power  is  lessened,  and  she  has  acquired  sterility. 

ii.  lJisturban,ce  of  vesical  or  rectal  functions. — The  patient  may  have 
frequent  desire  for  micturition  or  difficulty  in  securing  complete  evacu- 
ation of  the  bladder  or  the  rectum. 

iii.  General  pelvic  disturbance.  —  She  may  have  difficulty  in  walking 
or  in  working  with  a  mass  protruded  between  the  thighs.  Even  in  the 
incomplete  stages  she  may  have  a  sense  of  weight  and  dragging  in  the 
loins  or  groins.  In  many  cases  all  that  the  patient  complains  of  is 
the  presence  of  the  uterus  at  the  vulva  or  outside  of  it. 

Physical  Diagnosis.  — When  a  patient  comes  to  us  complaining  of  a 


DISPLACEMENTS   OF   THE    UTERUS  403 

falling  of  the  womb,  Ave  may  find  her  diagnosis  of  her  own  malady  to  be 
correct.  Sometimes,  instead  of  prolapsus  uteri,  we  may  find  another 
displacement,  such  as  retroversion  or  even  inversion ;  or  we  may  find 
that  an  intra-uterine  fibroid  has  become  pediculated,  and  is  in  course  of 
extrusion  through  the  canals.  The  body  that  has  appeared  at  the  vulva 
may  be  a  mucous  polypus  from  the  cervix ;  or  indeed  it  may  be  the  cer- 
vix itself  in  a  condition  of  hypertrophic  elongation.  There  may  be 
only  cystocele  or  rectocele,  without  uterine  dislocation ;  or  a  tumour 
growing  from  the  vaginal  wall  may  project  through  the  vulva.  The 
supposed  fallen  womb  may  even  prove  to  be  a  swelling  in  some  part 
of  the  external  pudenda,  such  as  a  neoplasm  or  cystic  accumulation,  or 
simple  hypertrophy ;  such  was  the  case  of  a  young  lady,  in  whom  the 
nymphse  were  unusually  long  and  dependent,  Avhose  mother  thought 
her  to  be  the  subject  of  prolapsus  uteri. 

Complete  prolapse  of  the  uterus  is  usually  very  easily  recognised  on 
inspection.  Hanging  from  the  vulva  between  the  patient's  thighs  is  seen 
a  mass,  the  size  of  a  fist,  pink  in  hue,  or  more  purj)le  if  the  tumour  be 
congested,  with  a  smooth  surface  except  when  erosive  patches  are  present, 
and  presenting  at  its  lower  anterior  aspect  the  external  orifice  of  the 
uterus.  Around  the  os  the  labia  sometimes  form  a  projection ;  often  it 
is  difficult  to  trace  the  line  of  demarcation  between  the  cervix  and  the 
vaginal  wall.  When  the  herniated  mass  is  grasped  between  the  fingers 
and  thumb  the  outline  of  the  entire  uterus  may  sometimes  be  felt  within. 
In  other  cases  one  feels  only  the  elongated  supravaginal  portion  of  the 
cervix,  round  and  hard ;  and  the  bimanual  examination  has  to  be  made  to 
ascertain  the  position  and  direction  of  the  body  of  the  uterus.  The  sound 
will  at  once  distinguish  the  os  uteri  from  a  fissure  in  a  fibroid  tumour 
that  might  have  descended  to  the  vulva ;  and  carried  up  through  the 
canal  the  sound  will  give  fuller  information  as  to  the  length  and  direction 
of  the  uterus  and  the  condition  of  its  parietes.  The  sound  (or  a  catheter) 
should  further  be  used  to  determine  the  direction  of  the  urethra  and  the 
exact  relations  of  the  bladder  cavity ;  and  a  finger  in  the  rectum  adds 
to  our  knowledge  of  the  size  and  place  of  the  uterus,  and  demonstrates 
the  degree  of  pouching  that  has  affected  the  bowel  itself. 

In  cases  of  incomplete  prolapse,  when  we  make  inspection  and  tell  the 
patient  to  bear  down,  we  can  see  the  unusual  mobility  of  the  anterior 
vaginal  wall,  and  recognise  the  os  as  it  becomes  depressed  towards  the 
vulva ;  and  the  bimanual  examination  reveals  to  us  the  relations  which 
the  uterus  has  assumed  in  the  lower  part  of  the  pelvis.  In  some  cases  the 
displacement,  Avhich  is  complete  Avhen  the  patient  is  in  the  upright  post- 
ure, disappears  when  she  lies  on  her  back.  Then  the  patient  can  be 
made  to  expel  the  Avomb  b}'  a  downbearing  effort ;  or  it  can  readily  be 
brought  down  by  traction  on  the  anterior  lip  of  the  os.  We  can  thus 
demonstrate,  as  it  were,  the  mechanism  of  the  herniation.  In  our 
examination  we  have  to  keep  in  view  not  merely  the  displacement,  but 
also  the  complications  that  may  attend  it ;  and  we  may  see  occurring 
rapidly  the  displacement  which  came  about  gradually  under  the  com- 


404  SYSTEM  OF  GYNECOLOGY 

bined  and  protracted  action  of  the  various  factors.  Through  the  patulo\is 
vulva  "the  anterior  vaginal  wall  is  exposed;  as  the  patient  bears  down, 
or  as  we  make  supra-pubic  pressure  through  the  abdominal  walls,  the 
vesico-vaginal  septum  is  seen  to  descend  until  tlie  anterior  fornix  vagina? 
comes  through  tlie  pudendal  aperture,  bringing  with  it  the  cervix  uteri. 
First  the  anterior  and  then  the  posterior  lip  of  the  os  externum  appears  ; 
and,  after  the  uterus  has  escaped,  the  posterior  wall  of  the  vagina  becomes 
inverted,  and  the  prolapsus  is  complete. 

Prognosis.  —  When  the  uterus  has  sunk  definitely  and  for  some  time 
from  its  normal  level,  it  has  no  natural  tendency  to  recover  its  proper 
place.  Two  physiological  conditions  may  modify  the  course  of  the 
mischief. 

i.  Influence  of  jrregnancy.  —  If  the  patient  become  pregnant,  and  due 
care  be  taken  to  prevent  abortion  or  aggravation  of  the  trouble  during 
the  first  three  months,  she  is  likely  to  be  freed  from  all  the  discomforts 
of  prolapse ;  as  the  uterus  from  this  time  onwards  rises  out  of  the  pel- 
vis and  becomes  an  abdominal  organ.  Sometimes  by  good  management 
of  the  labour  and  the  puerperium,  the  involution  of  the  uterus  may  be 
so  perfectly  secured,  and  the  tonicity  of  its  ligaments  so  far  restored, 
that  at  least  a  partial  cure  may  be  attained.  On  the  other  hand  it  more 
frequently  happens  that  the  displacement  recurs  after  the  patient  gets 
up ;  it  may  be,  in  an  aggravated  degree. 

ii.  Influence  of  the  menopause.  —  At  the  menopause  the  herniated 
organs  usually  undergo  the  ordinary  process  of  senile  atrophy  that  will 
lead  to  a  diminution  in  the  size  of  the  swelling  and  relief  from  some  of 
the  attendant  symptoms.  The  relaxation  of  the  ligaments  and  loss  of 
the  fatty  padding  of  the  pelvis  incidental  to  this  period  of  life  some- 
times, however,  allows  of  further  descent  of  the  uterus  ;  so  that  now  the 
patient  applies  for  relief  for  the  first  time  :  and  it  must  never  be  forgot- 
ten, in  the  cases  where  pessaries  have  been  long  worn  in  the  vagina,  that 
the  shrinkage  and  loss  of  vitality  in  the  walls  may  lead  to  ulcerative 
processes  to  which  the  tissues  had  shown  no  previous  tendency. 

Treatment.  —  A  prudent  practitioner  in  his  midwifery  practice  will 
keep  in  mind  the  risks  to  which  a  woman  is  subject  who  comes  out  of  her 
confinement  with  a  damaged  perineum,  relaxed  uterine  ligaments,  and 
subinvolution  of  the  uterus.  He  will  note  during  labour  the  conditions 
that  endanger  the  perineum  and  seek  to  avert  its  laceration.  Where 
laceration  has  occurred  he  will  see  to  its  immediate  repair,  bringing 
together  the  raw  surfaces  with  sutures  at  the  close  of  the  third  stage,  or 
within  twelve  hours  thereafter.  He  will  guide  the  convalescence,  and  see 
that  no  undue  exertions  are  allowed  until  the  ligiuiients  have  recovered 
their  tone,  and  tlie  uterus  is  restored  to  its  non-gravid  dimensions.  By 
such  prophylactic  measures  he  saves  his  patient  from  the  beginnings  of  a 
displacement  which  may  cause  little  disturbance  at  first,  but  which  will 
go  on  to  increased  distress,  and  may  be  a  source  of  trouble  for  a  lifetime. 

Where  the  prolapsus  uteri  is  complete  the  indication  for  treatment 
is  twofold :  to  reduce ;  and  to  retain  the  displaced  organ. 


DISPLACEMENTS   OF  THE    UTERUS  405 

i.  Reduction  of  the  uterus.  —  The  uterus,  whicli  is  completely  prolapsed 
when  the  patient  is  in  the  upright  position,  is  often  reduced  of  itself  when 
she  lies  down ;  so  far,  at  any  rate,  as  to  disappear  within  the  vaginal  ori- 
fice ;  or  when  not  spontaneously  replaced  it  may  be  made  to  return  with 
the  gentlest  amount  of  pressure.  Occasionally  some  degree  of  force  must 
be  exerted  ;  and  in  performing  taxis  in  such  cases  the  practitioner  has  to 
keep  in  mind  the  manner  in  which  the  herniation  occurred,  and  to  seek 
to  replace  the  structures  in  the  reverse  order  to  that  in  which  they 
descended.  He  begins  with  the  posterior  wall  of  the  vagina,  which  was 
the  last  to  escape,  and  presses  it  past  the  perineum.  The  uterus  follows, 
first  the  posterior  and  then  the  anterior  lip  of  the  cervix.  Last  of  all  the 
anterior  vaginal  wall  is  replaced.  It  is  especially  in  such  cases  that  the 
anterior  wall  is  found  to  have  become  greatly  thickened,  widened,  and 
indurated  in  its  texture.  In  some  instances  the  prolapsed  mass  is  so 
swollen  and  congested  that  the  patient  must  be  kept  at  rest  for  some  days 
before  the  reduction  can  be  safely  effected ;  and  during  that  time  she  may 
use  a  hot  sitz  bath,  or  have  a  stream  of  hot  Avater  made  to  play  over  the 
tissues  two  or  three  times  a  day,  so  as  to  reduce  the  hyperaemia.  It  may 
even  be  necessary,  for  this  purpose,  to  make  some  scarifications  on  the 
surface  to  relieve  the  vascular  tension.  Where  an  active  peritonitis  is 
present,  or  peritonitic  adhesions  have  formed  among  the  displaced  viscera, 
rude  or  rapid  manipulation  would  be  attended  with  danger ;  and  prolonged 
antiphlogistic  measures  should  be  employed  before  the  attempt  is  made  to 
replace  the  organs.  In  all  cases  the  reposition  should  not  onl}'  be  preceded, 
but  also  followed  by  the  adoption  of  an  antiphlogistic  treatment  calcu- 
lated to  lessen  the  uterine  hjq^ertrophy,  and  of  measures  calculated  to 
restore  the  tonicity  of  the  pelvic  tissues.  With  this  view  it  may  be 
necessary  to  curette  the  uterus,  and  to  apply  iodine  and  carbolic  acid  to 
the  interior ;  to  administer  ergot  and  quinine,  or  such  deobstruents  as  the 
iodide  and  bromide  of  potassium  ;  to  use  such  waters  as  those  of  Kreuz- 
nach,  Krankenheil,  Ems,  or  Kissingen,  and  to  enjoin  the  use  of  hot  and 
astringent  douches. 

Massage  has  been  employed  for  the  relief  of  this  as  of  other  pelvic 
mischiefs  ;  and  Thure  Brandt,  who  by  his  successful  treatment  of  various 
uterine  disorders  has  induced  some  members  of  the  profession  to  adopt 
the  practice  in  recent  years,  has  suggested  a  mode  of  reduction  of  the 
prolapsed  uterus  which  has  been  followed  by  various  g3'na?cologists  in 
different  countries  with  encouraging  results.  The  patient  under  treat- 
ment is  placed  on  her  back  with  her  knees  bent  up;  and,  while  an  assistant 
pushes  up  the  pelvic  organs  through  the  vagina,  the  operator  lays  hold 
of  the  body  of  the  uterus  with  the  finger-tips  of  his  two  hands  pressed 
through  the  abdominal  Avails  at  the  pelvic  brim.  AVhen  he  feels  that  he 
has  the  uterus  between  his  hands,  with  a  kind  of  wriggling  movement 
he  pulls  it  upwards  as  far  as  possible  into  the  abdominal  cavity.  This 
uplifting  of  the  organ  has  to  be  repeated  daily,  or  at  short  intervals  ;  and 
the  congestive  processes  are  at  the  same  time  relieved  by  friction  applied 
to  the  uterus  and  its  adnoxa  through  the  uterine  parietes.     But,  besides 


4o5  SyST£J/  OF  GYXMCOLOGY 

acting  thus  on  the  uterus  and  appendages,  tlie  operator,  placing  himself  at 
the  foot  of  the  couch,  tells  the  patient  to  keep  her  knees  as  tight  together 
as  possible,  whilst  he  forcibly  abducts  the  thighs  ;  and  again  he  tells  her 
to  try  to  keep  the  knees  apart  whilst  he  forcibly  brings  them  together. 
The  effect  of  this  alternate  action  of  her  adductor  and  abductor  muscles 
is  to  increase  the  vigour  of  the  muscular  structures  within  the  pelvis. 
This  is  further  favoured  by  stimulation  of  the  lumbar  muscles,  and 
gymnastic  exercises  calculated  to  develop  the  patient's  muscularity,  but 
these  are  not  essential  to  the  cure  of  the  prolapsus.  Those  who  have 
succeeded  in  this  "  kinesitherapeutic  practice,"  as  it  has  been  called,  have 
expressed  the  conviction  that  it  will  lessen  the  frequency  of  surgical 
operations ;  but  it  is  admitted  that  the  method  is  not  quickly  learnt,  and 
that  its  application  requires  long  fingers,  a  supple  hand,  muscular  activity 
and  dexterity,  and  inexhaustible  patience. 

ii.  Retention  after  replacement.  —  The  reduction  of  the  prolapsed  uterus 
is  usually  easy  of  accomplishment.  It  is  far  otherwise  with  its  retention 
in  place.  The  attempt  to  fulfil  this  indication  may  be  made  either 
by  the  application  of  some  kind  of  support;  or  by  the  employment 
of  some  operative  procedure.  The  former  line  of  treatment  is  for  the 
most  part  merely  palliative;  the  latter  aims  at  a  more  radical  cure. 

(a)  Palliative  measures.  —  Among  the  means  we  have  been  employing 
to  reduce  the  inflammatory  conditions  in  the  pelvis  an  important  place 
will  have  been  given  to  the  use  of  pledgets  of  cotton  soaked  in  glycerine. 
For  deobstrueut  purposes  the  glycerine  will  have  been  medicated  with 
ichthyol ;  where  a  more  astringent  action  is  desired  an  astringent  like 
tannin  will  have  taken  the  place  of  the  ichthyol.  These  pledgets  of 
cotton  may  so  fill  up  the  vaginal  cavity  as  to  have  at  the  same  time  the 
effect  of  supports  to  keep  the  uterus  in  place.  Or  the  vagina  may  be 
packed  tensely  with  iodoform  gauze  or  salicylated  cotton  wool ;  when  the 
packing  has  again  the  double  function  of  keeping  up  the  uterus  and  pro- 
moting absorption  of  inflammatory  deposits.  Such  vaginal  tampons 
require  to  be  changed  every  two,  three,  or  four  days.  Patients  can  wear 
a  tampon  of  marine  lint  for  a  week  without  any  discomfort ;  but  a  woman 
cannot  be  expected  to  go  on  for  any  length  of  time  using  vaginal  tampons 
that  may  require  the  assistance  of  the  medical  attendant  for  their  proper 
application.  Accordingly,  when  these  have  fulfilled  their  function  in 
lessening  the  pelvic  congestion,  and  have  demonstrated  that  a  foreign 
body  can  be  retained  in  the  vagina  which  prevents  the  recurrence  of  the 
prolapse,  the  practitioner  has  to  consider  what  kind  of  vaginal  pessary 
will  be  likely  to  keep  the  patient  comfortable.  Now  the  variety  of 
vaginal  pessaries  is  endless.     There  are  differences  in  — 

(a)  The  material  of  vaginal  pessaries.  —  They  are  sometimes  made  of 
metal.  Of  these  the  most  practical  are  the  rings  made  of  some  flexible 
material  that  allows  of  changes  in  their  form  to  suit  individual  cases. 
Pessaries  of  wood  were  at  one  time  in  frinpient  use;  and  tliey  liave  been 
made  also  of  ivory,  bone,  and  of  soft  materials  covered  with  some  im- 
pervious substance.     These  have  now  been  almost  entirely  replaced  by 


DISPLACEMENTS   OF  THE    UTERUS  407 

india-rubber,  either  in  its  soft  state  or  in  the  hard  state  of  vulcanite. 
The  soft  rubber  pessaries  have  the  advantage  of  easy  application  to 
a  wide  range  of  cases :  the  drawback  to  their  continuous  employment 
is  their  tendency  to  lose  elasticity  when  they  lie  for  a  length  of  time  in 
the  vagina ;  at  the  same  time  they  absorb  secretions  and  become  the 
source  of  disagreeable  discharges.  The  pessaries  of  vulcanite  can  be 
worn  for  long  periods,  without  undergoing  any  change  or  becoming  the 
source  of  any  trouble,  if  care  be  taken  to  see  that  they  are  properly 
adapted.  They  can  be  modified  in  form  by  being  placed  for  a  minute  in 
boiling  water ;  but  they  are  apt  to  break  when  attempts  are  made  thus 
to  change  their  curves  :  hence  it  is  necessary  for  the  gynaecologist  to  have 
a  set  of  vvdcanite  pessaries  of  different  size  and  outline  always  at  hand. 
If  he  can  procure  pure  gutta-percha  he  has  at  his  command  a  material  out 
of  which  he  can  fashion  a  pessary  for  any  given  case.  In  boiling  water 
gutta-percha  becomes  so  soft  that  a  piece  of  the  proper  size  can  be  rolled 
between  the  palms  of  the  hands  till  it  has  the  form  of  a  smooth  round 
ball ;  and  further  manipulation  can  then  mould  it  into  the  form  of  a  disc 
and  stem,  of  a  hollow  perforated  disc,  or  of  a  simple  ring  or  horse-collar, 
according  to  the  requirements  of  the  case.  Patients  have  sometimes  worn 
gutta-percha  pessaries  for  years  with  comfort.  But,  as  the  material  is 
somewhat  porous,  it  is  better  for  the  practitioner,  when  he  has  found  the 
form  and  size  that  suits  his  patient,  to  send  the  gutta-percha  instrument 
to  the  manufacturer  in  order  to  have  one  of  the  same  pattern  modelled 
in  vulcanite.  The  only  material  that  can  compete  with  vulcanite  in 
lightness,  smoothness,  and  freedom  from  irritation  in  the  vagina  is 
celluloid. 

(/3)  The  shape  of  vaginal  pessaries. — Globular  or  egg-shaped  pessaries, 
hollow  and  made  of  vulcanite,  are  very  serviceable  where  the  perineum 
has  still  some  retentive  power,  and  the  patient  suffers  from  a  tendency  to 
descent  of  the  vaginal  Avails  and  the  uterus ;  especially  in  elderly  women. 
In  many  cases  the  ring  pessary  gives  satisfactory  results.  The  soft 
india-rubber  ring  is  easily  introduced  and  adapted  to  the  vaginal  cavit3\ 
It  should  be  carried  up  so  as  to  lie  in  the  vaginal  roof,  the  posterior 
being  higher  than  the  anterior  border,  and  should  find  its  support  on  the 
upper  surface  of  the  plane  of  the  levator  ani.  Where  there  is  a  marked 
degree  of  cystocele  the  ring  should  be  filled  with  a  perforated  diaphragm 
which  serves  to  retain  the  anterior  vaginal  wall  better  in  position.  The 
soft  pessary,  however,  should  not  be  left  for  prolonged  wear ;  but  if  the 
ring  give  comfort  it  should  be  replaced  by  one  of  vulcanite  or  celluloid. 
Instead  of  a  simple  ring,  a  pessary  that  is  discoid  or  saucer-shaped  will 
often  retain  the  structures  better  in  position.  Such  a  pessary  holds  all 
the  better  if  the  posterior  border  be  made  thicker  than  the  anterior;  and 
it  may  be  worn  for  many  months  without  any  discomfort.  A  series  of 
perforations  allows  of  the  free  escape  of  the  menstrual  discharge,  and 
allows  of  the  washing  out  of  the  vaginal  cavity  with  the  douche.  Where 
the  ring  or  the  saucer-shaped  pessary  fails  to  keep  in  place,  the  herniation 
can  sometimes  be  prevented  by  making  the  patient  wear  a  disc  and  stem 


4o8  SYSTEM  OF  GYNAECOLOGY 

pessary ;  the  stem  projecting  from  the  lower  surface  of  the  disc  lies 
between  the  labia.  The  disc  may  be  circular,  but  is  better  elongated 
from  side  to  side  so  as  to  keep  the  walls  of  the  vagina  extended  trans- 
versely. The  patient  learns  easily  to  introduce  such  a  pessary  as  she  lies 
on  her  back,  by  passing  in  first  the  one  side  through  the  vaginal  orifice 
and  then  the  other,  as  a  button  is  passed  edgewise  through  a  buttonhole. 
She  removes  it  from  time  to  time  when  going  to  bed  by  laying  hold  of 
the  stem  with  the  finger  and  thumb  of  one  hand,  while  the  forefinger  of 
the  other  hand  lays  hold  of  one  edge  of  the  disc  and  presses  it  out.  She 
can  thus  secure  the  cleanliness  of  the  instrument  and,  if  need  be, 
she  can  douche  the  vaginal  cavity  in  the  interval  of  removal.  The 
Zwanck  and  other  pessaries  with  hinges  and  screws  are  all  unsatisfactory. 

"When  the  ball,  the  ring,  or  the  discoid  pessary  fail  in  consequence  of 
extensive  lacerations  of  the  perineum,  or  relaxation  in  the  muscular  planes 
of  the  pelvis,  the  patient  may  still  obtain  some  relief  from  her  displace- 
ment by  wearing  an  abdominal  bandage  in  addition  to  the  pessary.  A 
perineal  strap  passing  between  the  patient's  thighs  will  keep  the 
pessary  in  place ;  or  the  pessary  may  be  fixed  to  the  bandage  by  a 
curved  metallic  rod,  or  by  elastic  bands.  But  as  in  the  case  of  patients 
Avith  an  inguinal  hernia  where  a  truss  does  not  give  relief,  the  surgeon 
proposes  to  the  patient  an  operation  for  the  radical  cure,  so  here,  when 
there  is  a  multiplicity  of  arrangements  required  for  the  relief  of  the 
pelvic  hernia,  the  gynaecologist  will  suggest  that  it  is  better  to  have 
recourse  to  some  operative  procedure  likely  to  effect  a  cure  of  her 
condition. 

(6)  Operative  measures.  —  There  are  four  different  directions  in  which 
he  may  proceed  to  effect  his  purpose  of  securing  the  uterus  in  its  proper 
place,  and  he  is  guided  in  his  choice  partly  by  the  primary  fault  which 
initiated  the  displacement,  and  partly  by  the  changes  which  have  ensued 
in  the  dislocated  structures.  He  may  seek  (a),  to  lessen  the  pudendal 
aperture ;  (^),  to  narrow  the  vaginal  canal ;  (y),  to  diminish  the  size  of  the 
uterus;  (8),  to  tighten  the  uterine  ligaments.  In  some  cases  a  single 
operation  suffices  to  remedy  the  mischief;  in  others  two  or  more  of  the 
operations  must  be  carried  out  in  the  same  individual,  and  usually  he 
finds  it  best  to  perform  them  all  at  once  rather  than  at  intervals. 

(a)  ()p(!rations  on  the  pudendal  aperture.  — The  frequency  with  which 
the  dislocatory  process  follows  relaxation  or  rupture  of  the  perineum  warns 
us  that  in  a  large  proportion  of  cases  an  essential  elementintheradical  cure 
will  consist  in  the  tightening  of  the  pelvic  floor  and  narrowing  of  the 
pudendal  aperture.  Where  the  orifice  has  become  preternaturally  wide 
without  laceration  of  the  perineum,  the  operation  that  constricts  it  is 
designated  episiorraphy  ;  where  a  damaged  perineum  must  be  repai  rod  the 
operation  is  ii  peri  near  raphy.  Various  methods  have  been  followed  in  the 
attempt  to  narrow  the  aperture  and  to  strengthen  the  pelvic  floor  in  one 
operation,  by  making  a  raw  surface  extending  round  tlie  posterior  half  or 
two-thirds  of  the  vulva,  and  bringing  it  together  from  the  two  sides  with  a 
series  of  sutures.    The  best  results  are  obtained,  without  removal  of  any  of 


DISPLACEMENTS   OF   THE    UTERUS  409 

the  mucous  membrane,  by  splitting  off  the  vulvo-vaginal  mucous  mem- 
brane from  the  subjacent  tissue  either  with  a  knife  or,  more  rapidly,  with  a 
pair  of  scissors.  The  anterior  extremity  of  the  incision  on  each  side  comes 
at  least  as  far  forward  as  the  base  of  the  nymphte,  and  the  dissection  of 
the  mucous  membrane  proceeds  through  the  whole  extent  of  the  perineum 
until  the  point  is  reached  that  corresponds  to  the  junction  of  the  middle 
and  lower  third  of  the  vaginal  canal ;  there  some  areolar  tissue  only 
intervenes  between  the  vagina  and  the  rectum.  Where  the  perineal 
damage  has  invaded  the  anal  canal  the  recto-vaginal  septum  has  to  be 
split  higher  up  ;  and  while  the  dissection  is  carried  forward  to  the  usual 
extent  in  the  direction  of  the  nymphae,  in  this  case  it  must  also  be  carried 
backwards  around  the  anal  gap  beyond  a  dimple  or  depression  which  can 
usually  be  seen  in  the  cicatricial  tissue  on  each  side,  indicating  the  point 
of  insertion  of  the  ends  of  the  sphincter  ani  which  is  torn  across.  Such 
dissection  produces  a  raw  surface  of  large  extent,  in  the  sides  and  depth 
of  which  the  torn  or  relaxed  musculo-fascial  tissues  are  freely  exposed. 
These  may  now  be  brought  together  by  means  of  a  continuous  catgut 
suture,  which  is  introduced  at  first  in  the  centre  of  the  vaginal  flap  and 
is  carried  backwards  towards  the  anal  margin  from  side  to  side  in  the 
depth  of  the  wound.  It  then  runs  forward,  laying  hold  of  the  sides 
of  the  wound  in  the  middle  of  the  raw  surface ;  and  the  next  stage, 
which  again  runs  backwards,  brings  the  edge  of  the  wound  into  close 
apposition. 

(/3)  Operations  on  the  vaginal  Avails.  —  When  pessaries  have  been  left 
so  long  unattended  to  in  the  vagina  that  they  have  produced  ulcerative 
processes  in  the  vaginal  walls,  their  removal  is  sometimes  followed  by  a 
cicatricial  contraction  of  the  canal  which  makes  the  patient  independent 
of  further  aid.  In  such  patients,  however,  the  non-recurrence  of  the  pro- 
lapse is  not  due  simply  to  the  nai*rowing  of  the  hernial  canal,  but  to  the 
changes  that  have  taken  place  also  in  the  uterus  and  its  ligaments ;  for  they 
are  usually  women  who  have  passed  the  climacteric  period  with  its  atrophic 
processes,  and  the  uterus  has  long  been  kept  up  in  its  normal  place.  The 
attempt  to  prevent  prolapse  by  producing  a  cicatricial  ring  in  women  at  an 
earlier  age,  and  whilst  the  uterus  is  still  subject  to  its  menstrual  changes, 
is  not  encouraging  in  its  results.  A  circular  ulcer  has  been  made  by  means 
of  the  actual  cautery  high  up  in  the  vagina ;  or  a  tape  has  been  passed 
round  underneath  the  mucous  membrane  and  tied  so  tightly  as  to  ulcer- 
ate its  way  out.  The  circular  scar,  however,  that  results  is  continuously 
strained  by  the  heav}^  uterus,  and,  receiving  no  support  from  the  relaxed 
tissues  below,  becomes  distended  in  no  long  time  ;  the  uterus  thus  sinks 
through,  and  the  whole  prolapse  is  reproduced. 

The  most  satisfactory  results  are  obtained  by  the  procedures  that 
narrow  the  vagina,  not  in  a  circular,  but  in  a  longitudinal  direction.  Raw 
surfaces  two  inches  in  length  and  nearly  as  broad,  made  on  corresponding 
portions  in  the  middle  of  the  anterior  and  posterior  walls,  have  been 
iorought  together  so  as  to  produce  a  strong  bridge  which  prevents  pro- 
lapse ;  or  the  anterior  and  pcisterior  walls  have  been  sewn  together  after 


41  o  SYSTEM   OF  GYNAECOLOGY 

the  iniicous  merabrane  lias  been  dissected  off  tlie  sides  of  tlie  canal.  The 
procedure  that  is  usually  indicated  has  been  called  anterior  or  posterior 
colporruplvj  or  ehjtrorraphy,  which  signify  a  narrowing  of  the  anterior  or 
posterior  wall  of  the  vagina  throughout  their  length.  In  some  cases  the 
posterior  colporraphy  constitutes  part  of  the  operation  for  perineal  repair, 
some  portion  of  the  redundant  mucous  membrane  on  the  back  wall  of  the 
vagina  being  dissected  off,  and  the  wound  closed  by  sutures  running  from 
side  to  side  so  as  to  narrow  the  cavity  just  above  the  perineum.  Most 
frequently  the  indication  is  for  an  anterior  colpo^raph3^  The  anterior 
vaginal  Avail  was  the  first  part  to  undergo  displacement ;  it  gradually  be- 
comes distended,  thickened,  and  indurated;  and  whilst  these  changes  may 
be  modified  by  keeping  the  patient  at  rest,  by  the  wearing  of  pessaries, 
or  by  narrowing  of  the  vulvar  orifice,  they  can  only  be  effectually  re- 
moved by  a  surgical  operation.  A  circular  portion  of  the  mucous  mem- 
brane may  be  dissected  off  the  most  prominent  part  of  the  wall,  and 
the  wound  closed  like  the  mouth  of  a  purse  by  a  suture  that  runs  round 
the  margin.  Raw  surfaces  about  half  an  inch  in  breadth  may  be  made 
towards  the  side  of  the  wall,  and  brought  together  in  the  centre  of  the 
canal  by  means  of  silver  sutures  kept  in  place  for  three  weeks.  These 
raw  surfaces  are  wider  apart  in  the  fornix  and  converge  toward  the 
urethra.  Better  still  it  is  to  make  an  elongated  elliptical  wound  surface, 
the  upper  end  of  which  begins  close  to  the  cervix  uterus,  widening  as  it 
goes  down  till  in  the  middle  the  entire  breadth  of  the  wall  is  denuded  of 
its  mucosa,  and  narrowing  again  as  it  comes  down  toward  the  urethral 
orifice.  A  continuous  catgut  suture  closes  the  wound  in  stages.  Intro- 
duced at  the  urethral  end,  it  narrows  the  raw  surface  as  it  is  carried  from 
side  to  side  till  it  reaches  the  cervical  end ;  as  it  is  carried  down  again 
towards  the  lower  extremity  it  brings  the  sides  of  the  wound  together 
near  the  mucous  membrane  at  the  widest  part ;  and  in  its  third  stage,  as 
it  is  again  passed  upward,  it  will  bring  together  the  mucous  membrane 
at  the  margins.  This  operation  narrows  the  anterior  wall,  constricts 
the  vaginal  canal  throughout  its  length,  and,  when  conjoined  with  the 
perineal  repair  which  is  likely  to  be  required,  gives  the  surest  hope  of  a 
radical  cure  in  the  great  run  of  cases  of  prolapsus  uteri. 

(y)  Operations  on  the  uterus.  —  When  the  uterus  itself  is  enlarged, 
whether  primarily  or  secondarily,  it  becomes  necessary  to  secure  its  dimi- 
nution by  other  than  the  ordinary  antiphlogistic  measures.  This  often 
occurs  spontanecjusly  to  a  remarkable  degree  during  the  time  when  the 
jjatient  has  to  ke(q)  at  rest  after  a  perineorraphy  or  colporrajjhy  ;  and  will 
all  the  more  certainly  and  completely  take  place  if  these  operations  have 
been  preceded  by  a  curetting  of  the  uterine  cavity.  If  cervical  hypertro- 
phy be  j^resent,  amputation  of  the  cervix,  or  of  some  portion  of  it,  may 
form  the  leading  indication.  It  may  be  that  one  or  both  of  the  lips  or 
the  entire  infravaginal  portion  has  to  be  removed,  and  when  the  patient 
has  recovered  from  the  effects  of  tlie  operation  the  uterus  will  retain  its 
place.  In  other  instances  the  amputation  must  go  further;  the  intei- 
mediate  portion  must  Ije  dissected  from  the  bladder  so  as  to  allow  of  its 


DISPLACEMENTS   OF   THE    UTERUS  411 

removal.  Extirpation  of  the  entire  uterus  has  sometimes  been  carried 
out.  In  most  of  these  cases  of  prolapse  vaginal  hysterectomy  will  be 
easy  of  accomplishment;  but  this  operation  should  be  reserved  for 
patients  in  whom  there  is  some  tendency  to  malignant  degeneration. 

(8)  Modifyiivj  the  mvpjiorts  of  the  uterus.  —  Two  different  procedures 
that  were  proposed  in  the  first  instance  for  the  cure  of  backward  displace- 
ments of  the  uterus,  have  been  found  serviceable  in  some  cases  of  descent. 
These  are  the  shortening  of  the  round  ligaments,  suggested  inde- 
pendently by  Dr.  Alexander  of  Liverpool  and  Dr.  Adams  of  Glasgow, 
and  usually  named,  after  them,  the  Alexander- Adams  operation ;  and 
the  fixation  of  the  uterus  to  the  abdominal  parietes ;  the  so-called 
ventro-fixation  or  hysteropexia.  Various  gynaecologists,  both  British  and 
foreign,  have  reported  favourable  results  from  the  employment  of  these 
procedures ;  but  the  range  of  their  applicability  has  not  been  clearly 
defined,  and  where  they  are  undertaken  the  patient  should  be  made 
aware  of  the  attendant  risks. 

B.  Deviations  in  Position 

The  uterus  may  be  placed  unusually  far  (i.)  backwards,  in  a  state  of 
retro-position ;  (ii.)  forwards,  in  a  state  of  antero-position  ;  or  (iii.)  to  one 
or  other  side  —  right  or  left  —  lateri-position.  These  displacements  of  the 
uterus  may  be  due,  on  the  one  hand,  to  tumours,  inflammatory  effusions, 
or  haemorrhagic  extravasations  pushing  the  organ  out  of  its  place ;  or,  on 
the  other,  to  peritonitic  adhesions  or  cellulitic  contractions  pulling  it  in 
another  direction.  For  example,  a  cellulitic  swelling  in  the  left  broad 
ligament  in  its  early  acute  stage  will  thrust  the  uterus  towards  the  right 
side  of  the  pelvis ;  and  if  the  inflammatory  process  end,  as  it  sometimes 
does,  in  producing  an  atrophy  of  the  ligament,  the  uterus  will  eventu- 
ally be  dragged  towards  the  left  side.  So  a  peritonitic  effusion  in  the 
pouch  of  Douglas,  in  the  acute  stage,  will  press  forward  the  uterus  which, 
at  a  later  period,  if  the  parts  become  flxed  by  inflammatory  adhesions, 
will  be  retro-posed.  It  is  obvious  that  these  malpositions  of  the  uterus 
do  not  constitute  the  central  phenomenon  in  any  individual  case  ;  still  it 
is  important  to  keep  them  in  mind,  because  they  are  often  found  compli- 
cating some  of  the  other  displacements,  and  obscuring  the  diagnosis. 

They  can  usually  be  recognised  by  means  of  the  bimanual  examina- 
tion supplemented,  if  need  be,  by  the  use  of  the  sound  or  volsella :  their 
treatment  falls  under  the  treatment  either  of  the  causes  that  produce 
them,  or  of  the  displacements  with  which  they  co-exist. 

C.  Deviations  in  Direction 

The  uterus  is  subject  to  changes  in  the  direction  of  the  fundus, 
which  may  be  displaced  backwards,  forwards,  or  to  one  or  the  other  side. 
In  either  case  there  are  two  different  conditions  of  the  uterus  itself  to  be 
observed  :  in  one,  the  whole  uterus  is  more  or  less  rotated  on  its  axis,  the 


412  SYSTEM  OF  GYNECOLOGY 

body  and  the  neck  of  the  uterus  form  a  straight  line,  the  uterus  is  in  a 
state  of  version,  and  we  have  retroversion,  anteversion,  or  lateriversion. 
In  the  other  case  the  body  has  mainly  or  alone  undergone  the  change ; 
the  body  is  bent  on  the  neck,  the  uterus  is  in  a  state  of  flexion,  and  we 
have  to  do  with  retroflexion,  anteflexion,  or  lateriflexion.  The  most 
important,  from  the  practitioner's  point  of  view,  are  the  — 

I.  Posterior  Deviations. — These  have  sometimes  been  described 
under  the  convenient  designation  of  retrorsions  —  a  term  which  includes 
the  cases  where  the  entire  uterus  is  displaced,  the  retroversions,  and  those 
where  the  body  chiefly  is  displaced  and  bent  on  the  cervix  —  the  retro- 
flexions. In  a  simple  retroversion  the  uterus  has  lost  its  tendency  to  fall 
forward  towards  the  symphysis  pubis;  the  organ  is  to  some  degree  stiftened 
so  that  the  cavity  of  the  body  and  canal  of  the  cervix  form  a  continuous 
line ;  and  it  has  become  rotated  on  its  axis  so  that  the  fundus  remains 
permanently  directed  towards  the  sacrum,  and  the  os,  instead  of  looking 
backwards,  is  directed  downwards  or  forwards  according  to  the  degree  of 
version  that  has  been  established.  The  varying  degrees  of  retroversion 
in  individual  cases  should  be  estimated  by  noting  whether  the  fundus 
is  directed  towards  the  promontory  of  the  sacrum,  or  towards  the  first 
or  a  lower  sacral  vertebra.  In  a  case  of  retroflexion  the  uterus  has 
not  only  lost  the  normal  anterior  inclination,  the  body  has  also  become 
permanently  bent  backwards.  The  os  may  still  look  backwards  ;  but,  as 
in  most  cases  of  retroflexion  there  is  some  degree  of  retroversion  present, 
the  OS  will  come  to  change  its  direction  also :  thus  in  well-marked  cases 
the  fundus  is  found  lying  in  the  lowest  part  of  the  pouch  of  Douglas, 
and  the  os  looking  towards  the  lower  margin  of  the  pubic  symphysis. 

Causes  of  Retrorsions.  —  Before  studying  causes  on  the  part  of  the 
uterus  itself,  on  the  part  of  its  ligaments,  or  on  the  part  of  the  influences 
that  tend  to  bring  about  these  changes  in  the  direction  of  the  uterus,  we 
may  note  that  some  cases  are  :  — 

i.  Concjenital.  —  On  post-mortem  examination  of  infants  and  young 
children  the  uterus  is  sometimes  found  retroverted  or  retroflexed  to  a 
degree  not  to  be  accounted  for  by  the  dorsal  decubitus  of  the  body.  In 
young  married  women  the  displacement  may  be  present  when  there  is 
no  antecedent  history  to  lead  us  to  suppose  that  ordinary  operative 
causes  have  been  at  work.  I  have  seen  two  sisters,  one  married  and 
the  other  single,  suffering  from  retroflexion ;  and  the  displacement  reap- 
pearing in  the  two  daughters  of  the  marricid  one.  This  congenital  dis- 
))lacement  is  soinetim(!s  associated  with  elongation  of  the  cervix  or  with 
shortening  of  the  vagina,  notably  of  the  anterior  wall ;  but  it  may  also 
occur  without  any  concomitant  deformity. 

ii.  Changes  in  the  uterus.  —  Whatever  causes  tend  to  produce  (a) 
induration  of  the  uterine  tissues,  and  ,so  to  destroy  its  normal  flexibility, 
tend  to  bring  about  a  version  of  the  organ.  Subinvolution,  chronic 
inetritis,  and  tumours  in  the  walls,  whicli  make  the  organ  rigid  and 
urifil)h!  i-cadily  to  accommodate  itself  to  the  distensions  and  evacuations  of 
ihf  nfi'^lihoiiriiig  organs,  especially  of  the  bladder,  render  it  liable  to  be 


DISPLACEMENTS    OF   THE    UTERUS  413 

affected  by  the  influences  that  press  the  fundus  backwards,  and  so  to 
suffer  retroversion.  Hence  the  frequency  of  this  displacement  in  women 
who  have  given  birtli  to  one  or  more  children,  and  have  subsequently 
remained  sterile;  for  these  chronic  inflammatory  changes  in  the  uterus 
are  very  apt  to  arise  in  connection  with  puerperal  processes,  whether  they 
begin  in  the  placental  site,  as  suggested  by  the  elder  Martin,  or  in  other 
parts  of  the  uterine  parietes.  When  the  anterior  wall  is  chiefly  affected 
a  retroversion  will  result;  and  this  the  more  certainly  the  lower  down  in 
the  wall  the  thickening  is  situated.  (6)  Of  relaxation  of  uterine  structure 
retroflexion  is  more  likely  to  be  the  consequence.  In  cases  of  persistent 
retroflexion  a  notable  atrophy  of  the  posterior  wall  is  usi;ally  found  at 
the  point  of  flexure  which  corresponds  to  the  isthmus.  In  some  instances 
this  may  be  a  consequence  and  not  a  cause  of  the  flexion ;  but  in 
others  loss  of  substance  as  well  as  loss  of  tone  precede  the  displacement 
and  favour  its  occurrence ;  and  in  some  patients,  Avhere  both  anterior  and 
posterior  walls  are  found  thus  thinned  and  relaxed  at  the  isthmus,  the 
uterus  is  liable  at  one  time  to  be  retroflexed  and  at  another  in  a  state  of 
exaggerated  anteflexion. 

iii.  Changes  in  the  ligaments.  —  It  is  in  the  loss  of  retentive  power  of 
some  of  its  ligaments  that  we  most  frequently  find  the  explanation  of  a 
retroversion.  AVhen  (a)  the  utero-sacral  ligaments  are  relaxed  the  cervix 
is  liable  to  be  carried  too  far  forward,  and  then  the  fundus  is  likely  to  fall 
backwards ;  (h)  the  retroversion  is  favoured  when  the  round  ligaments 
are  relaxed,  and  fail  in  their  function  of  keeping  the  fundus  directed 
towards  the  abdominal  wall :  but  whilst  loss  of  tone  in  the  utero-sacral 
and  round  ligaments  is  the  most  important  element  in  the  production  of 
retroversion,  we  note  (c)  that  the  changes  in  these  ligaments  are  frequently 
conjoined  with  relaxation  of  the  broad  ligaments  and  of  the  structures  in 
the  floor  of  the  pelvis.  We  have  seen,  in  dealing  with  prolapsus  uteri, 
how  influential  are  these  conditions  in  leading  to  descents  of  the  organ  ; 
and  we  then  note  that  descent  is  apt  to  be  attended  with  retrover- 
sion and  retroflexion.  There  is,  however,  another  ligamentous  change 
which  may  be  chargeable  with  the  production  of  a  backward  deviation  of 
the  uterus.  This  occurs  when  (d)  the  utero-vesical  ligaments  are  shortened 
as  a  result  of  chronic  inflammation.  The  tense  structures  dragging  the 
isthmus  forwards,  or  keeping  it  somewhat  immobile,  prevent  the  uterus 
as  a  whole  from  making  the  exciirsions  in  various  directions  demanded  by 
its  relations  to  the  neighbouring  organs.  The  body  renuiining  more 
mobile  than  the  cervix,  and  retaining  its  normal  flexibility,  is  apt  to  be 
turned  back  into  the  hollow  of  the  sacrum,  and  a  retroflexion  is  thus 
established. 

iv.  Directly  displacing  influences.  —  Of  the  influences  that  tend  im- 
mediately to  produce  retro-deviations  of  the  uterus,  we  may  note —  (a)  A 
strain  or  fall  or  other  jar  to  the  body  which  has  sometimes  preceded  the 
appearance  of  symptoms  associated  with  a  retroversion  or  retroflexion  of 
the  uterus.  In  some  such  cases  the  pre-existing  displacement  nuiy  not 
have  been  recognised;  in  others  it  is  easily  conceivable  that  a  displace- 


414  SYSTEM  OF  GYNECOLOGY 

nient  could  be  thus  brought  about,  especially  if  at  the  time  of  the 
accident  the  fundus  Avere  lifted  backwards  by  a  distended  bladder.  (6) 
Habitual  over-distension  of  the  bladder,  which  will  keep  the  fundus  uteri 
directed  to  the  promontory  of  the  sacrum  or  beyond  it :  and  a  patient 
in  whom  the  uterus  is  frequently  in  this  situation  will  readily  acquire  a 
permanent  retroflexion;  and  this  all  the  more  if  the  bowels  have  a 
tendency  to  constipation  and  require  straining  efforts  for  their  evacuation, 
(c)  A  permanent  backward  fixation  of  the  uterus  which,  in  some  eases,  is 
a  resiilt  of  peritonitis  leading  to  adhesions  that  bind  the  posterior  surface 
of  the  uterus  to  the  rectum  and  back  wall  of  the  pelvis. 

Complications.  — When  tumours  of  the  uterus  itself  or  of  the  neigh- 
bouring organs  are  associated  with  retroversion  the  displacement  is  of 
minor  moment,  and  it  usually  disappears  on  removal  of  the  growth.  The 
most  important  complications  depend  on  the  tendency  to  inflammatory 
changes  in  the  uterus.  These  inflammations  are  sometimes  the  cause, 
sometimes  the  consequence  of  the  displacement ;  in  either  case  the  dis- 
placement and  inflammation  tend  to  perpetuate  and  to  aggravate  each 
other.  The  inflammatory  mischief  may  be  found  in  the  perimetrium, 
leading  to  fixation  of  the  uterus  in  the  pouch  of  Douglas ;  or  it  may 
affect  the  mesometrium,  producing  a  rigidity  that  especially  perpetuates 
the  retroversions.  Most  frequently  the  endometrium  is  affected ;  and 
there  is  a  chronic  catarrhal  process  in  the  cavity  of  the  uterus,  which  is 
likely  to  spread  along  the  cervical  canal  and  to  pass  out  on  the  posterior 
lip  in  the  form  of  an  extensive  granulating  catari'hal  patch.  Among  the 
most  troublesome  cases  are  those  in  which  the  retroversion  is  complicated 
with  prolapse  of  the  ovaries,  because  these  glands  are  usually  congested 
and  tender  when  they  become  thus  displaced,  and  may  cause  trouble  in 
the  adjustment  of  pessaries  which,  in  other  cases,  would  serve  to  retain 
the  uterus  in  position  and  relieve  the  patient  of  her  suffering.  More- 
over, it  has  often  been  found  on  section  that  retroversions  of  the 
uterus  have  so  far  interfered  with  the  function  of  the  ixreters  as  to 
have  produced  some  degree  of  hydronephrosis.  This  rarely  attracts 
attention  during  life ;  but  it  is  noteworthy  that  a  considerable  proportion 
of  women,  who  are  the  subjects  of  movable  kidney,  have  at  the  same 
time  some  uterine  displacement,  most  frequently  in  the  form  of  retrover- 
sion or  retroflexion. 

The  symptoms  of  retrorsions  of  the  uterus  are  due  partly  to  the 
displacement,  and  partly  to  the  inflammatory  changes  that  so  frequently 
accompany  or  flow  from  it.     They  consist  of  — 

i.  Disturbance  of  uterine  functions.  — This  disturbance  may  affect  either 
the  menstrual  or  reproductive  functions,  and  in  many  cases  both  of  these 
functions  are  disordered. 

(a)  Menstrual  disorders. — While  an  amenorrluBic  ])atient  may  have 
a  retroflexed  uterus,  as  in  some  cases  of  sui)eriiiv()ltition  or  in  some  cases 
of  hydrornetra  or  haimatometra,  j)atients  who  ai'o  tlie  sul)jects  of  retrover- 
sion or  retroflexion  usually  suffer  from  increase  of  the  menstrual  flow ;  in 
many  instances,  indeed,  it  is  because  of  the  menorrhagia  that  they  seek 


DISPLACEMENTS   OF   THE    UTERUS  415 

advice.  The  excessive  flow,  however,  is  symptomatic  of  the  attendant 
endometritis  rather  than  of  the  mere  displacement.  Sometimes  dys- 
menorrhoea  running  throughout  each  menstrual  period  is  a  leading 
symptom  ;  and  whilst  in  some  cases  this  also  finds  its  explanation  in  the 
inflammatory  condition  of  the  uterus,  in  others  it  is  associated  with  the 
displacement;  especially  in  cases  where  the  uterus  is  so  retroflexed  as  to 
have  lost  its  erectile  power,  and  where  mechanical  straightening  of  the 
organ  relieves  the  menstrual  pain.  Intermenstrual  discharges,  again, 
presenting  any  of  the  characters  of  leucorrhosa,  are  most  frequently  due 
to  catarrhal  processes  in  the  cervix  or  body  of  the  uterus. 

(6)  Eeproductive  disorders.  —  If  retroflexion  be  found  in  a  patient 
who  complains  of  dyspareunia,  the  explanation  of  the  suffering  will 
usually  be  found  in  some  of  the  complications  that  are  present  —  such  as 
vaginismus  or  oophoritis  —  unless  the  displaced  organ  be  itself  the  seat  of 
an  active  inflammation.  Sterility,  on  the  other  hand,  is  often  the  result 
of  retroflexion,  and  thus  a  leading  symptom  of  it.  This  may  be  the  case 
in  women  who  have  never  conceived.  I  have  treated,  for  instance,  two 
sisters  in  each  of  whom,  after  two  or  three  years  of  childless  marriage, 
the  uterus  was  found  retroflexed ;  in  both  of  them  conception  occurred 
after  the  uterus  had  been  replaced  with  the  sound  and  kept  in  place  with 
a  vaginal  pessary.  Still  more  constantly  one  finds  the  viterus  turned 
back  in  the  case  of  women  who  have  given  birth  to  one  or  more  children 
and  then  cease  to  conceive.  There  are  others,  again,  in  whom  conception 
occurs  from  time  to  time,  but  who  bear  no  more  children  because,  with  a 
retro  verted  uterus,  they  become  the  subjects  of  habitual  abortion. 

ii.  Disturbance  of  neighbouring  organs.  — We  have  seen  how  much 
the  positions  of  the  uterus  are  modified  by  the  changing  relations  of 
the  adjacent  viscera.  When  it  loses  its  power  of  adaptation  to  these 
organs,  and  is  persistently  displaced,  it  may  prove  a  source  of  irritation 
to  them.     Hence  we  have  — 

(a)  Interference  with  the  rectum.  —  The  patient  sometimes  suffers 
from  mucous  dejections  and  frequent  desire  for  def aecation ;  more 
frequently  there  is  obstruction  to  the  easy  escape  of  the  intestinal 
contents,  and  the  bowels  are  emptied  with  severe  straining  efforts. 

(b)  Interference  with  the  bladder.  —  The  bladder  may  be  unaffected ; 
but  the  patient  who  has  a  retroverted  uterus  is  liable  to  suffer  from 
frequent  calls  to  micturition,  or  diflieulty  in  evacuation  of  the  bladder, 
especially  if  the  uterus  be  at  the  same  time  enlarged.  A  patient  who 
has  not  menstruated  for  two  or  three  months  and  suffers  from  retention 
of  urine  is  almost  sure  to  have  retroversion  of  the  gravid  uterus. 

(c)  Interference  with  pelvic  muscles  and  nerves.  — Patients  with  re- 
troversion or  retroflexion  of  the  uterus  sometimes  seek  advice  because 
of  pain  referred  to  the  pelvic  cavity,  to  the  sacrum,  or  to  the  lower 
extremities.  In  some  the  suffering  is  aggravated  by  any  kind  of 
exertion;  in  others,  where  there  is  no  pain,  there  is  loss  of  power  in  the 
lower  extremities,  so  that  the  patient  appears  paraplegic,  and  is  only  able 
to  walk  when  the  uterus  has  been  righted  and  retained  iu  its  proper  place. 


4i6  SYSTEM  OF  GYNECOLOGY 

(d)  General  constitutional  disturbance.  —  Besides  the  more  localised 
symptoms  we  may  find  the  patients  complaining  of  derangements  of  more 
distant  organs,  such  as  the  reflex  neuralgias,  gastric  distress,  mammary 
irritation,  and  general  depression  that  are  so  often  associated  with  other 
forms  of  uterine  trouble. 

The  diagnosis,  however,  of  a  retroversion  or  retroflexion  of  the  uterus 
cannot  be  founded  merely  on  these  functional  symptoms.  It  can  only  be 
made  out  by  direct  physical  examination. 

i.    Abdominal  palpation  gives  negative  results. 

ii.  Vaginal  exploration.  —  The  finger  introduced  into  the  vagina  finds 
the  OS  looking  downwards  or  even  directly  forward ;  the  anterior  fornix 
empty  ;  and  the  posterior  fornix  occupied  by  a  rounded  resistant  body, 
which,  if  a  second  finger  be  introduced,  is  felt  to  be  continuous  with  the 
cervix  and  to  move  in  concert  with  it.  To  acquire  certainty  as  to  the 
condition  our  great  reliance  is  placed  on  — 

iii.  Bimanual  examination.  —  The  fingers  of  the  left  hand  applied  to 
the  hypogastric  region  press  down  the  uterus  and  its  adnexa  so  deeply  into 
the  pelvis  that  the  index  and  medius  of  the  right  hand,  by  which  the 
vaginal  exploration  is  made,  get  more  fully  into  contact  with  all  the 
pehac  viscera.  The  forefinger  being  placed  on  the  cervix  uteri  and 
the  middle  finger  in  the  posterior  fornix  vaginae,  the  exact  relations  of  the 
uterus  can  in  most  instances  be  distinctly  defined.  If  it  be  retroverted 
the  body  is  found  running  directly  backwards  whilst  the  os  looks  for- 
ward; and  if  there  be  retroflexion  the  angle  at  Avhich  the  body  is  bent 
on  the  cervix  can  be  felt.  In  this  manner,  after  a  little  experience, 
the  practitioner  succeeds  in  diagnosing  the  condition  with  the  greatest 
certainty.  Occasionally  greater  certainty  is  attained  by  introducing  the 
medius  into  the  rectum  whilst  the  index  explores  by  the  vagina. 

iv.  Use  of  the  sound.  —  As  gynaecologists  first  learned  to  appreciate  the 
frequency  of  retroflexions  of  the  iiterus  by  the  use  of  the  sound  before 
the  liiinanual  method  had  been  fully  developed,  so  the  young  practitioner 
will  often  find  it  useful  to  satisfy  himself  of  the  direction  of  the  body 
of  the  uterus  by  passing  the  sound  in  a  case  where  his  bimanual  ex- 
ploration still  leaves  him  in  doubt.  There  are  even  cases  where  the 
most  experienced  gynaecologist  is  glad  to  avail  himself  of  its  services  ; 
especially  if  the  displacement  be  associated  with  tumours  or  with  hsemor- 
rhagic  or  inflammatory  effusions.  There  are  cases  where  the  bimanual 
examination  is  impeded  by  the  thickness,  or  painful  because  of  the  tender- 
ness of  the  abdominal  walls;  the  passage  of  the  sound  then  speedily  and 
{)ainlessly  clears  up  the  diagnosis. 

V.  Other  aids  to  diagnosis.  —  The  volsella  may  sometimes  be  used  to 
pull  upon  the  cervix,  or  the  speculum  may  be  introduced  to  determine 
the  condition  of  the  lips  of  the  os  uteri.  Por  determination  of  the 
displacement  in  itself  they  are  unnecessaiy.  But  to  get  the  full  benefit 
of  bimaniuil  examination  it  is  oftfMi  necessary  to  bring  the  ])atient  und(!r 
an  anaesthetic.  This  becomes  the  more  necessary  where  any  tumours  or 
adhesions  are  likely  to  interf(u-(!  with  the  easy  reposition  of  the  organ; 


DISPLACEMENTS    OF  THE    UTERUS  .        417 

indeed,  it  may  be  dangerous  to  the  patient  to  ;indertake  the  treatment 
of  a  case  when  these  are  overlooked. 

Prognosis.  — "  lis  ne  tuent  pas,  mais  ils  ne  guerissent  pas,"  said 
Velpeau  in  one  of  the  discussions  in  the  French  Academy  of  Medicine, 
when  some  of  his  confreres  who  were  averse  to  the  employment  of 
pessaries  argued  that  displacements  of  the  uterus  were  not  dangerous 
to  life.  Retroversion  or  retroflexion  of  the  uterus  are  assuredly  not 
conditions  likely  to  prove  fatal,  but  they  may  be  sources  of  life-long 
discomfort.  The  only  conditions  under  which  a  patient  with  this  dis- 
placement may  get  rid  of  her  trouble  would  be  (i)  in  the  rare  cases 
Avhere,  having  escaped  the  danger  of  abortion,  she  has  carried  a  child 
to  the  full  term,  and  a  normal  involution  of  the  uterus  and  its  ligaments 
has  been  secured  during  the  puerperium ;  or  (ii)  Avhen  the  uterus  under- 
goes such  atrophy  as  sets  in  at  the  menopause. 

Treatment.  —  When  a  retroversion  or  retroflexion  of  the  uterus  is 
found  in  a  patient  who  comes  complaining  of  the  symptoms  described 
in  the  preceding  paragraphs,  the  practitioner,  before  proceeding  to  deal 
with  the  displacement,  must  make  sure  that  it  is  an  uncomplicated 
case.  In  a  very  great  proportion  of  instances  the  first  indication  he 
has  to  fulfil  is  — 

i.  To  combat  the  comjjUcations.  —  Among  these  the  inflammations  in 
and  around  the  uterus  hold  a  foremost  place.  It  is  sometimes  difficult 
to  determine  whether  the  patient's  distress  be  more  due  to  the  inflam- 
mation or  to  the  displacement ;  and  it  often  enough  happens  that  under 
antiphlogistic  measures  the  walls  of  a  rigidly  retroverted  uterus  become 
softened,  or  the  flaccid  Avails  of  a  retroflexed  uterus  recover  their  toni- 
city and  the  organ  rights  itself.  So  perimetritic  adhesions  may  become 
relaxed,  cicatricial  indurations  of  the  utero-vesical  ligaments  may  dis- 
appear, or  tension  be  restored  to  utero-sacral  ligaments  that  had  lost 
their  contractility ;  spontaneous  reposition  of  the  displaced  viscus  may 
thus  come  about.  When,  after  inflammatory  conditions  have  been 
removed,  the  uterus  retains  its  abnormal  place,  the  inflammatory  changes 
will  all  recur  imless  the  uterus  be  replaced.  There  are  many  cases, 
moreover,  where  reposition  of  the  uterus,  without  special  antiphlogistic 
treatment,  is  followed  by  removal  of  the  congestive  and  catarrhal 
symptoms.     The  next  indication,  accordingly,  is  to  — 

ii.  Replace  the  uterus.  —  Various  methods  have  been  adopted  for 
securing  the  reposition  of  the  retrorse  uterus. 

(a)  Posturing  the  patient.  —  When  the  patient  is  placed  in  the 
knee-elbow  posture,  and  the  perineum  is  pulled  back,  so  as  to  allow 
the  vagina  to  be  filled  with  air,  the  vaginal  roof,  carrying  with  it  the 
uterus,  can  be  seen  and  felt  to  have  fallen  away  downwards  and  for- 
wards. This  posturing  of  the  patient  and  manipulation  of  the  parts 
has  sometimes  been  used  for  the  purpose  of  replacing  the  retroverted 
uterus.  The  manoeuvre  has  been  specially  commended  imder  the  idea 
that  the  patient  by  adopting  it  might  succeed  in  freeing  herself  of  the 
displacement.     But  whilst  in  a  few  cases  of  retroversion   the  uterus 

2e 


4iS 


SYSTEM   OF  GYX.-ECOLOGY 


might  b}"  this  means  fall  into  its  normal  relations,  in  the  great  majority 
it  will  fail  to  do  so.  In  them,  and  in  all  cases  of  retroflexion,  when  the 
patient  is  put  in  the  genu-pectoral  position  and  the  perineum  held  back, 
it  becomes  necessary  to  pull  the  cervix  downwards  and  outwards  mth 
a  volsella  grasping  the  anterior  lip  of  the  os,  while  the  fundus  is  pushed 
into  its  proper  place  either  through  the  posterior  fornix  vaginae  or 
through  the  rectum. 


1  "' ' 

Fig.  lis.  —  Reposition  of  the  rotroverted  uterus  witli  the  sound. 

(6)  Bimanual  reposition.  —  Wlien  a  patient  has  been  chloroformed 
for  the  purpose  of  careful  diagnosis  the  best  method  of  reposition  is 
by  the  bimanual  procedure.  The  fingers  of  the  one  hand  are  pressed 
through  the  al)dominal  walls  towards  the  hollow  of  the  sacrum ;  and, 
while  the  middle  finger  of  the  other  hand  pushes  the  fundus  upwards  to 
bring  it  within  reach  of  the  abdominal  fingers,  the  forefinger  is  used  to 
push  the  cervix  Ijackwards  until,  under  the  concerted  action  of  the  two 
hands,  the  fundus  is  carried  right  forward  to  the  symphysis  pubis. 
Occasionally  the  fundus  can  be  pushed  up  better  by  the  medius  inserted 
into  the  rectum.  Even  when  the  patient  is  not  anaesthetised  this 
manipulation  can  in  many  cases  be  carried  out  without  much  difficulty, 
especially  where  the  abdominal  walls  are  thin  and  flaccid. 


DISPLACEMENTS    OF   THE    UTERUS 


419 


(c)  Reposition  with  the  sound.  — ^Vhen  the  practitioner  is  satisfied 
that  he  has  to  do  with  a  uterus  tliat  is  not  bound  down  by  adhesions, 
liis  simplest  and  speediest  method  of  reposition  is  by  means  of  the  uterine 
sound.  It  can  be  effected  with  perfect  safety  if  the  operator  be  careful 
to  move  the  handle  through  a  wide  area,  as  the  point  of  the  sound  turns 
within  the  uterine  cavity  (see  Fig.  118) ;  and  in  this,  as  in  other  methods 
of  reposition,  it  is  necessary  to  carry  the  fundus  uteri  far  forward  till  it 
comes  to  lie  close  to  the  symphysis. 


Fig.  119.  —  Hods:c  pessary  in  the  vagina  retaining  the  uterus  in  sifii. 

In  a  few  cases  it  suffices  thus  to  replace  the  uterus,  and  to  place  a 
])ledget  of  cotton  and  glycerine  in  the  anterior  fornix,  when  the  organ 
maintains  its  proper  set.  Usually,  however,  it  returns  sooner  or  later  to 
its  abnormal  position ;  and  in  many  cases  the  retrorsion  is  reproduced 
almost  immediately  on  the  withdrawal  of  the  sound  or  of  the  replacing 
fingers.     The  next  indication  to  be  fulfilled,  therefore,  is  the  — 

iii.  Maintenance  in  place.  —  For  this  the  application  of  a  vaginal 
pessary  in  the  form  of  a  simple  ring  will  sometimes  suffice.  l>etter  still 
is  the  introduction  of  a  Hodge  pessary  (Fig.  119),  or  Albert  Smith's  very 


420  SYSTEM   OF  GYNAECOLOGY 

"widely  serviceable  modification  of  the  Hodge  pessary.  In  some  cases 
this  pessary  is  borne  with  more  comfort  if  the  upper  bar  be  thickened, 
as  in  the  pessaries  of  Gaillard  Thomas  and  Prochownick.  Where  the 
utero-sacral  ligaments  are  greatly  relaxed,  Schultze's  figure-of-eight  pes- 
sary, or  his  sleigh  pessary,  may  become  necessary. 

"When  we  have  to  deal  with  retroflexions  the  vaginal  pessary  may  be 
insuftieient  to  retain  the  uterus  in  its  place,  and  benefit  is  to  be  obtained 
by  the  cautious  introduction  of  an  intra-uterine  stem.  The  Amann  intra- 
uterine vulcanite  stem,  fixed  on  the  edge  of  a  disc,  does  good  service  in 
keeping  the  uterus  straight ;  and  Avhen  the  anterior  fornix  is  packed  with 
iodoform  gauze,  or  with  pledgets  of  cotton  or  glycerine,  the  xiterus  is 
retained  in  position,  and  the  walls  recover  their  tone ;  when  three  or  four 
periods  have  passed  the  organ  may  keep  its  place,  or  be  kept  in  it,  by 
the  use  of  a  vaginal  pessary.  Instead  of  a  rigid  stem  of  vulcanite  a  soft 
india-rubber  stem  pessary,  which  is  more  easily  retained,  may  be  passed 
into  the  uterus.  The  intra-uterine  pessary  sometimes  has  to  be  supported 
and  supplemented  by  the  use  of  the  vaginal  pessary ;  but  care  should 
be  taken  not  to  fix  the  two  pessaries  together  in  any  such  fashion  as  to 
interfere  with  the  movements  which  the  uterus  must  necessarily  undergo 
in  the  changing  relations  of  the  pelvic  viscera. 

Where  patients  continue  to  suffer  from  the  effects  of  retroversion  or 
retroflexion  of  the  uterus  unrelieved  by  mechanical  appliances  and  anti- 
phlogistic remedies,  we  must  consider  whether  by  some  operative 
interference  a  cure  may  be  effected.  It  has  been  proposed  to  fix  the 
cervix  uteri  to  the  back  wall  of  the  vagina,  but  experiments  made  in 
this  direction  have  not  been  encouraging.  Better  results  have  been 
obtained  from  shortening  of  the  round  ligaments.  Where  the  uterus 
has  acquired  adhesions  that  cannot  be  relaxed  or  severed  by  bimanual 
manipulations  the  operation  of  laparotomy,  which  will  allow  of  the 
freeing  of  the  uterus  and  its  subsequent  ventro-fixation,  becomes  jus- 
tifiable. Several  operators  have  recently  reported  satisfactory  results 
from  a  colpotomy  which  allows  of  the  fundus  uteri  being  reached  through 
the  anterior  fornix  and  fixed  anteriorly.  The  peritoneal  cavity  has 
even  been  opened  into  by  the  sacral  method ;  and  after  the  uterus  has 
been  freed  from  adhesions  the  fundus  has  been  carried  forwards,  and  the 
pouch  of  Douglas  obliterated  so  as  to  prevent  relapse  of  the  displacement. 
Such  procedures,  however,  should  be  reserved  for  cases  where  the 
retrorsion  of  tlie  uterus  is  complicated  with  some  other  condition,  such 
as  displacement  or  disease  of  the  ovaries,  which  aggravates  the  patient's 
distress,  and  forbids  the  relief  that  can  ordinarily  be  afforded  by  properly 
adjusted  pessaries.  Some  time  must  elapse  before  their  ultimate  results 
and  their  relative  values  can  be  ascertained,  and  no  conscientious 
practitioner  would  subject  a  patient  to  an  operation  extending  to  the 
peritoneal  cavity  without  explaining  to  her  the  dangers  to  which  she 
will  be  exposed. 

ir.  Antkkior  Dkviations.  —  At  one  time  many  of  the  cases  of  dys- 
inenorrlioia  and  sterility  tliat  came  undci-  oljservatiou  were  supposed  to 


DISPLACEMENTS    OF   THE    UTERUS  421 

be  cases  of  anteversion,  or  more  frequently  of  anteflexion  of  the  uterus; 
and  were  maltreated  as  such.  But  since  gynaecologists  have  recognised 
that,  with  the  bladder  empty,  the  uterus  is  normally  in  a  position  of  com- 
bined anteversion  and  anteflexion,  they  have  been  less  disposed  to  look 
to  these  antrorsions  for  an  explanation  of  the  sufferings  of  their  patients. 
Some  would  even  eliminate  the  anterior  displacements  altogether  from  the 
category  of  iiterine  disorders,  and  only  admit  the  existence  of  a  patho- 
logical anteversion  or  anteflexion  when  they  can  lay  their  finger  on  the 
condition  that  causes  or  keeps  up  the  dislocation.  But,  however  freely 
Ave  admit  that  the  sufferings  associated  with  these  displacements  are  trace- 
able to  the  causes  that  bring  them  about,  or  to  the  complications  that 
attend  them,  there  remains  a  residuum  of  cases  in  which  the  practitioner 
finds  that  he  cannot  effect  a  cure  of  his  patient's  condition  without  hav- 
ing regard  to  the  displacement,  and  using  means  to  correct  it.  As  in  the 
posterior  deviations,  so  here  the  entire  uterus  may  be  rigid  and  rotated  on 
its  transverse  axis,  giving  the  condition  of  anteversion  ;  or  the  body  may 
be  bent  more  or  less  acutely  on  the  cervix  in  the  state  of  anteflexion. 

Causes  and  Complications  of  Antrorsions.  — i.  Concjenital.  — In  early 
life  the  normal  anteflexion  of  the  uterus  is  very  pronounced,  and  it  is  at 
the  period  of  puberty  that  the  body  of  the  organ  develops  more  decidedly, 
and  tends  to  become  more  erect ;  then  the  congestion  of  each  menstrual 
epoch  is  attended  with  a  distinct  straightening  of  the  utero-cervical  canal. 
In  some  patients,  however,  such  erection  of  the  organ  fails  to  occiir ; 
and  though  for  a  time  menstruation  may  go  on  painlessly,  it  is  apt,  in 
course  of  some  months,  to  be  attended  with  suffering.  The  uterus  in 
such  cases  sometimes  presents  some  other  deformity,  such  as  elongation 
of  the  cervix,  or  stenosis  of  the  os ;  or  it  is  attached  to  a  vagina  with 
unusually  short  walls. 

ii.  Changes  in  the  vferns.  —  Inflammatory  changes  in  the  uterus  may 
lead  to  an  induration  of  the  walls  that  gives  a  proclivity  to  anteversion, 
or  to  relaxation  or  atrophy  of  the  tissues  at  the  isthmus  which  will  favour 
exaggeration  of  the  normal  anteflexion.  But  by  far  the  greatest  number 
of  women  who  have  pathological  anteflexion  of  the  uterus  have  also  — 

iii.  Changes  in  the  ligaments.  —  It  is  in  inflammatory  contractions  of 
the  utero-sacral  ligaments  that  we  so  frequently  find  the  explanation  of 
this  distortion  of  the  uterus.  As  they  lay  hold  of  the  isthmus  these 
ligaments,  when  they  become  shortened,  drag  the  cervix  uteri  towards 
the  hollow  of  the  sacrum ;  and,  as  the  body  of  the  uterus  retains  its  mobil- 
ity', it  becomes  bent  in  an  exaggerated  degree  by  the  pressure  of  the 
superincumbent  structures:  the  organ  as  a  whole  loses  its  power  of 
adapting  itself  to  the  movements  of  the  adjacent  organs.  The  same 
effect  is  sometimes  produced  when  adhesions  have  formed  in  the  pouch 
of  Douglas  which  fix  the  cervix  to  the  rectum  but  leave  the  fundus  free 
to  become  permanently  anteflexed. 

iv.  Direct!)/  displacing  influences.  —  Whilst  increased  weight  or  relaxa- 
tion of  texture  of  the  uterus, and  abnormal  shortenings  of  its  posterior  liga- 
ments, favour  the  occurrence  of  the  anterior  deviations,  they  are  directly 


422  SYSTEM  OF  GYX.ECOLOGY 

produced  by  pressure  bearing  on  the  posterior  surface  of  the  organ.  Tlie 
ordinary  intra-abdominal  pressure  may  of  itself  produce  the  result  under 
favourable  conditions ;  but  in  some  patients  there  is  further  pressure 
from  the  presence  of  tumours,  or  even  from  habitual  constipation.  In 
some  very  rare  instances  the  uterus  is  fixed  forAvard,  as  the  result  of 
inflammatory  adhesions  that  have  formed  between  the  fundus  and  the 
bladder  or  anterior  abdominal  wall. 

The  causes  that  bring  about  the  displacement  very  commonly  remain, 
to  some  extent,  as  complications  of  the  mischief;  and  they  have  to  be 
carefully  kept  in  view  in  the  treatment  of  every  case :  moreover,  as 
many  of  these  patients  become  the  subjects  of  salpingitis  and  oophoritis 
as  well,  the  possibility  of  these  complications  being  present  must  never 
be  forgotten. 

The  symptoms  that  chiefly  attract  attention  here  are  dysmenorrhoea 
and  sterility.  The  patients  may  also  have  leucorrhcBa,  or  trouble  with 
the  bladder  or  bowels,  or  be  the  subjects  of  pelvic  and  other  pains ;  but, 
for  the  most  part,  they  come  under  observation  as  young  unmarried 
women  suffering  from  dysmenorrhoea,  or  as  young  married  women  who 
have  never  conceived,  and  are  perhaps  also  clysmenorrhoeic.  The  men- 
strual pain  is  often  due  to  the  chronic  utero-sacral  cellulitis  or  other 
conditions  causing  the  displacement;  sometimes  it  is  due  to  the  stenosis 
that  complicates  it ;  sometimes  it  is  to  be  referred  to  the  endometritis 
that  may  in  one  patient  be  the  cause  of  the  anteflexion,  and  in  another 
the  conserpience  of  it.  There  are  yet  others  where  the  flexion  leads  to 
suffering  because  of  the  obstacle  to  the  easy  outflow  of  the  menstrual  fluid 
from  a  uterus  that  has  lost  its  erectile  property.  As  regards  the  sterility, 
we  note  that,  whilst  we  find  retroversion  in  a  large  proportion  of  the 
women  who  have  given  birth  to  one  or  more  children,  and  then  have  ac- 
quired sterility,  a  greater  number  of  those  who  are  absolutely  sterile,  and 
have  never  conceived  at  all,  are  the  subjects  of  anteflexion  of  the  uterus. 
As  with  the  dysmenorrhcea,  so  the  sterility  may  sometimes  find  its  expla- 
nation in  the  concomitant  conditions  ;  but,  when  these  have  all  been  com- 
bated, there  remains  a  group  of  cases  where  the  patient  does  not  conceive 
until  means  are  used  to  correct  the  displacement. 

The  diagnosis  is  made  by  bimanual  exploration,  which  enables  us  to 
make  out  tlie  size,  direction,  and  relations  of  the  uterus.  The  posterior 
j)arametritis  or  perimetritis  that  may  have  been  the  prime  factor  in 
bringing  about  the  anteflexion  is  very  likely  to  have  produced  at  the  same 
time  some  degree  of  retroposition  of  the  organ,  so  that  an  imperfect 
exploration  may  lead  to  the  diagnosis  of  a  retroversion.  Even  with  the 
greatest  care  it  is  in  some  patients  diflicult  to  make  out  the  exact  position 
of  the  fundus,  unless  the  abdominal  walls  are  thin,  or  the  muscles  are 
relaxed  under  chloroform.  The  sound  is  often  helpful  in  determining  the 
direction  of  the  fundus.  To  facilitate  its  introduction  it  may  have  to  be 
V)ent  pretty  sharply  towards  the  point;  but  the  most  important  matter 
to  attend  to  in  emjdoying  it  in  these  cases  is  to  avoid  force  in  passing 
it  onwards.     When  the  point  meets  with  resistance  at  the  flexure,  the 


DISPLACEMENTS   OF   THE    UTERUS  423 

handle  should  simply  be  pressed  backwards  towards  the  perineum,  when 
the  finger  in  the  anterior  fornix  will  feel  the  body  of  the  uterus  settle 
down  over  the  end  of  the  instrument,  and  the  diagnosis  is  made  sure. 

The  treatment  must  have  regard,  in  the  first  instance,  to  the  various 
conditions  that  may  be  found  causing  or  complicating  the  displacement. 
Until  the  hypertrophied  uterus  is  reduced  in  size,  its  tense  ligaments 
relaxed,  and  the  inflammatory  processes  in  and  around  it  subdued  by  the 
use  of  douches,  vaginal  plugs,  medicated  pessaries  and  the  like,  it  will  be 
vain  to  attempt  to  relieve  the  patient's  symptoms  by  mechanical  meas- 
ures calculated  to  correct  the  uterine  displacement.  For  some  gynaecolo- 
gists the  treatment  of  pathological  anteflexion  would  simply  resolve 
itself  into  the  treatment  of  uterine  or  pelvic  inflammations.  But  it  is 
to  be  remembered  that  the  resorption  of  inflammatory  deposits  may 
sometimes  be  favoured  by  the  appliances  that  have,  at  the  same  time, 
the  effect  of  improving  the  position  of  the  uterus  ;  and  if  symptoms  re- 
main unrelieved  by  other  measures,  there  is  a  clear  indication  for  their 
employment.  It  has  been  found  time  after  time  that  an  intra-uterine 
stem  pessary  has  promoted  the  disappearance  of  the  endometritis  which 
attends  anteflexion  ;  dysmenorrhoeic  jDatients  have  menstruated  without 
suttering;  the  uterus  was  thus  kept  straight,  and  women  previously 
sterile  have  conceived  with  the  stem  in  the  uterus.  It  must  be  borne 
in  mind  that  with  any  active  inflammation  in  or  around  the  uterus  the 
employment  of  stem  pessaries  is  a  source  of  danger,  whether  in  the 
posterior  or  in  the  anterior  displacements.  The  instruments  used  should 
be  carefully  sterilised  and  applied  with  antiseptic  precautions.  When 
the  intra-uterine  stem  is  to  be  worn  for  some  time  it  is  usually  necessary 
to  introduce  vaginal  plugs  below  it,  or  to  apply  a  vaginal  pessary.  In 
cases  of  anteversion  a  vaginal  ring  or  a  figure-of-eight  pessary  is  often 
of  use  in  relieving  some  of  the  pressure  symptoms. 

Operative  measures  of  various  kinds,  such  as  the  fixation  of  the  cervix 
to  the  anterior  wall  of  the  vagina  in  cases  of  anteversion,  and  opening  the 
pouch  of  Douglas  to  alloAV  of  removal  of  wedge-shaped  pieces  from  the 
back  of  the  uterus  in  cases  of  anteflexion,  have  been  proposed  and  carried 
out.  But  though  the  operators  have  given  favourable  reports  of  their 
cases,  the  operative  treatment  of  the  anterior  displacements  of  the 
uterus  does  not  offer  much  prospect  of  triumph  for  plastic  surgery. 

III.  Lateral  Deviations. — Lateral  deviations  of  the  uterus  are 
occasionally  met  with  in  practice  ;  there  may  be  dextroversion  or  dextro- 
flexion  when  the  uterus  is  turned  or  bent  towards  the  right,  or  sinistro- 
version  or  sinistroflexion  when  the  deviation  is  towards  the  left  side  of 
the  pelvis.  These  variations  are  usually  found,  however,  as  subsidiary 
phenomena  in  association  with  inflammations,  hasmatomas,  or  other 
tumours ;  or  they  may  complicate  the  anterior  or  posterior  displace- 
ments of  the  organ.  Hence  they  are  of  relatively  small  clinical  impor- 
tance ;  they  give  rise  to  no  distinctive  symptoms ;  and  their  diagnosis  and 
treatment  are  to  be  conducted  according  to  the  principles  applicable  to 
the  detection  and  treatment  of  the  more  common  deviations. 

A.  R.  Simpson. 


424 


SYSTEM  OF  GYNAECOLOGY 


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22.  Kustner.  "  Die  Behandlung  complicirter  Retroflexionen  und  Prolapse  be-sonders 
durch  ventrale  Operationen,"  Volkmann's  Samndung, 'No.  9;  1890:  and  "  Eine  einfache 
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Scheidenpessarien,"  Archiv  fiir  Gynaekologie,  xliii.  373.  1893. — 30.  Olshausen. 
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I'Uterus  cliez  la  femme  adulte,"  Archives  gdnerulcs  de  niddecin.e,  i,  274.  18(19. — 
.32.  PiiornowNicK.  "  Ueber  Pessarien,"  Volkmann's  Sammlung,  No.  225.  1883. 
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n(!Orrhaphie  dnrcli  Spaltung  des  Septum  Recto-vaginale  und  Lapi>eiibildung,"  KoZ/r- 
mann's  Sniiniilini'/,  No.  .'lOl.  1888. — .35.  Von  SrANZoNi.  "Ueber  die  Abtriignng  der 
Vaginal  porlion  als  Mittcl  zur  Heilung  des  Gebarmuttfirvorfalls,"  Bc.rtrllge  zur  Geburt- 
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MORBID    CONDITIONS   OF  FEMALE    GENITAL    ORGANS        425 

xii.  213.  1886.  —  37.  Schucking.  "  Eine  neue  Methode  der  Radicallieilung  der  Eetro- 
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zu  Berlin.  1894. — 47.  Von  Winckel.  Die  Behandlung  der  Flexionen  des  Uterus  mit 
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"  Ueber  Thiire  Brandt's  Verfahren  der  Behandlung  von  Frauenleiden,"  Volkmann's 
Sammlung,  Nos.  353,  354.     1890. 

A.  E.  S. 


THE    MORBID    CONDITIONS    OF    THE    FEMALE    GENITAL 
ORGANS   RESULTING  FROM  PARTURITION 

(Lacerations,  Fistulas,  Morbid  Ixvolution) 

The  two  Kinds  of  Injury  in  Child-birth 

Many  of  the  diseases  to  which  women  are  liable  arise  from  injury 
received  in  child-birth. 

Two  kinds  of  injury  may  occur  :  (1)  The  tissues  may  be  mechanically 
damaged ;  (2)  micro-organisms  and  poisons  produced  b}^  them  ma}'  get 
into  the  tissues.  Either  kind  of  injuiy  may  result  in  much  after  suffer- 
ing; often  both  injuries  are  combined. 

In  the  pages  which  follow  I  shall  describe  the  mechanical  injuries 
which  may  occur  in  child-birth,  and  the  effects  of  them  which  may  persist 
after  child-birth  is  over.  The  diseases  to  which  these  injuries,  by.  per- 
mitting the  access  of  micro-organisms,  may  indirectly  give  rise,  are 
described  in  other  sections  of  this  System. 

The  mechanical  injuries  are  of   two  kinds :    (A)  tearing,  and  (B) 


426  SYSTEM   OF  GYNECOLOGY 

crushing.  I  shall  first  describe  tearing ;  and  I  shall  take  first  the  part 
which  is  the  first  to  be  torn. 

Mechanical  Ixjukies  —  A.  Tearing. — I.  The  Cervix  Uteri. — In 
some  few  labours  the  os  uteri,  solely  by  stretching,  expands  to  a  size 
large  enough  to  let  the  child  pass.  But  in  most  cases,  as  the  force 
which  is  dilating  the  os  increases  as  the  size  of  the  os  increases,  this 
force  shortly  before  delivery  becomes  very  great,  and  the  enlargement 
of  the  OS  is  finished,  not  by  stretching,  but  by  tearing.  If  the  accoucheur 
add  to  the  force  by  pulling  with  forceps  before  dilatation  is  complete, 
the  tearing  is  generally  greater  than  in  deliveries  left  to  nature.  The 
tears,  whether  produced  by  unaided  nature  or  by  the  forceps,  are  gener- 
ally lateral.  They  may  involve  only  the  vaginal  portion,  or  they  may 
extend  up  to  the  os  internum  (see  Fig.  122),  down  into  the  vagina,  and 
outwards  into  the  cellular  tissue.  They  are  often  multiple,  running  in 
a  stellate  fashion  from  the  os  uteri ;  but  if  so,  the  lateral  tears  are  usually 
the  deepest.  Big  rents  are  said  to  be  most  frequent  on  the  left  side ;  but 
the  preponderance  is  not  great.  Rents,  great  or  small,  are  so  frequent 
that  their  presence  is  a  valuable  presumptive  evidence  of  antecedent 
child-birth. 

As  some  persons  think  that  these  tears  entail  very  important  after- 
effects, the  first  practical  question  is  whether  anything  can  be  done  to 
prevent  such  effects  ? 

Should  tears  of  the  cervix  he  sewn  up  at  once? — Some  writers  have 
advised  accoucheurs  to  sew  up  all  tears  of  the  cervix  at  once.  This  is 
difficult  and  troublesome.  Moreover,  as  Freund  has  pointed  out,  these 
tears  are  irregular,  and  in  the  condition  of  parts  after  delivery  it  is  dif- 
ficult to  follow  them  up.  The  accoucheur  may  think  he  has  sewn  up 
the  whole  of  a  tear  when  there  remains  a  gap  above  or  outside  his  line 
of  suture  which  he  has  not  perceived ;  and  his  stitches,  by  preventing 
free  exit  of  discharge  from  such  a  spot,  may  favour  retention  and  de- 
composition of  discharge,  and  thus  produce  blood  poisoning.  In  sew- 
ing up  a  deep  rent  it  is  possible  to  include  the  ureter  in  the  stitches. 
During  the  involution  of  the  uterus  these  tears  heal  to  a  large  extent ; 
I  therefore  agree  with  Freund,  that  the  suture  of  lacerations  of  the 
cervix  immediately  after  delivery  is  only  desirable  when  required  to 
stop  bleeding. 

T7ie  results  of  cervical  lacerations.  — Each  tear  of  the  cervix  is  an  open 
wound.  If  during  lying-in  the  g(uiital  organs  are  kei)t  clean,  and  the 
lochia  flow  away  projjerly,  the  wouuds  heal.  The  opposite  surfaces  of  the 
tear  may  unite,  and  then  no  trace  of  it  remains :  but  they  seldom  do, 
and  tlie  wound  usually  heals  by  granulation.  Epithelium  on  one  side 
develops  from  the  mucous  membrane  of  the  vaginal  surface  of  the  cervix, 
on  the  other  side  from  that  of  the  cervical  canal,  and  a  fibrous  scar  is 
formed  where  they  meet. 

When  the  cervix  surroimding  the  os  externum  has  thus  been  made 
into  two  lips,  with  a  gap  between  them,  and  the  patient  gets  up,  the 
intra-abdominal  pressure  drives  the  cervix  uteri  against  the  posterior 


INJURIES  IN  PARTURITION  427 

vaginal  wall.  This  pressure  forces  the  lips  of  the  cervix  asunder,  and 
eversion  of  the  lower  part  of  the  cervical  canal  is  the  result.  By  this 
eversion  mucous  membrane,  which  should  not  be  exposed  to  any  friction 
or  pressure,  is  exposed  to  friction  and  pressure  against  the  vagina.  The 
effects  of  such  friction  and  pressure  are  not  the  same  in  every  case.  In 
some,  the  part  of  the  cervical  canal  exposed  by  eversion  undergoes 
changes  which  make  it  like  that  of  the  vaginal  portion ;  its  columnar 
epithelium  becomes  changed  into  squamous,  its  rugte  become  less  prom- 
inent and  may  be  effaced,  and  its  colour  becomes  the  same  pale  bluish 
pink  as  that  of  the  vaginal  portion.  There  is  no  inflammation  of  the 
cervix;  its  lips,  although  everted,  are  not  thickened,  and  no  symptoms 
arise.  This  change  is  more  likely  to  happen  if  the  involution  of  the 
uterus  has  gone  on  well. 

In  other  cases,  and  especially  in  those  in  which  there  is  subinvolu- 
tion, the  friction  and  pressure  produce  and  keep  up  chronic  inflamma- 
tion of  the  cervix.  Its  lips  become  not  only  everted,  but  swollen ; 
instead  of  their  profile  (on  section)  being  conical,  as  in  Fig.  120,  it  be- 
comes club-shaped,  as  in  Fig.  121.  Its  surface  often  becomes  the  seat 
of  the  adenomatous  growth  known  as  "  erosion "  —  which  name  was 


Fig.  120. —Profile  on  section  of  Fig.  121.  —  Profile  on  section  of  lacer- 

lacerated,  but  healthy,  cervix  ated  and   inflamed    cervix  uteri 

uteri  (diagrammatic).  (diagrammatic). 

applied  to  it  before  its  histological  structure  was  known.  The  growth, 
as  its  name  implies,  is  one  of  gland  tissue.  The  orifices  of  these  newly 
formed  glands  often  become  blocked,  the  secretion  is  retained,  and  the 
gland  becomes  converted  into  a  cyst  containing  a  clear  viscid  fluid,  a 
muco-purulent  fluid,  or  pus.  These  cysts  may  remain  after  all  other 
signs  of  adenomatous  growth  have  disappeared. 

The  symptoms  and  treatment  of  the  inflammation  of  the  cervix  thus 
produced  or  kept  up  by  the  eversion  resulting  from  laceration  are  de- 
scribed in  the  section  on  Inflammatory  Diseases  of  the  Uterus. 

II.  The  Vagina.  —  Considerable  injuries  to  the  vagina  seldom  occur 
during  the  spontaneous  birth  of  a  living  child,  or  even  when  the  delivery 
of  such  a  child  is  skilfully  helped  Avith  forceps;  slight  abrasions  and 
shallow  fissures,  however,  can  be  found  after  most  first  labours,  if  looked 
for,  in  the  lower  third  of  the  vagina. 

Conditions  favouring  injuries  to  the  vagina.  —  But  laceration  of  the 
vagina  sometimes  takes  place  even  when  the  child  is  born  without 
assistance.  There  are  four  conditions  which  make  the  vagina  more  than 
usually  liable  to  be  torn.  These  are  (1)  contraction  of  the  vagina  by 
fibrous  tissue :  either  parametritic  exudation  which  has  become  organised 


4-S 


SVSl^EJ/   OF  GYX^^COLOGY 


into  fibrous  tissue,  or  scar  tissue  left  after  operations  for  vaginal  fistula?, 
rupture  of  the  perineum,  or  the  removal  of  vaginal  cysts.     (2)    In  the 


Fio.  122.  — (After  Freiind.)  Laooi-ations  of  corvlx  uteri  and  vapliia.  Krom  nature.  (The  anterior  part 
of  the  vagina,  part  of  tho  Ijlarldor  and  pubic  bones,  l)avo  boon  removed,  and  a  probe  and  draina^-o 
tubes  innerU'-d  in  tlie  laeeratlons.) 

older  priiniparfifi  tlie  tissues  stretcli  biull y,  .'uid  arc;  therefore  more  likely 
to  be  torn.     {'<))    Liicei-atiou  of  tlie  vagina  has  \)va\\v  obstu'ved  in  cases  of 


INJURIES  IN  PARTURITION  429 

difficult  labour  with  small  pelves,  and  it  has  been  inferred  that  the  tear- 
ing has  happened  because  the  vagina  was  small  as  well  as  the  pelvis  j 
l)ut  in  such  cases  there  is  more  than  usual  compression  of  the  vagina 
between  the  head  and  the  pelvis ;  moreover  instrumental  delivery  is 
more  often  needed :  these  circumstances  are  to  my  mind  a  better  expla- 
nation of  the  frequency  of  laceration  of  the  vagina  than  a  hypothetical 
smallness  of  the  canal.  (4)  In  some  pelves  the  normal  bony  promi- 
nences are  more  pronounced  than  usual ;  among  them  the  ischial  spines. 
If  this  be  the  case,  the  vagina  is  especially  liable  to  laceration  where  it 
is  compressed  between  the  foetal  head  and  these  bony  points.  Tearing 
of  the  vagina  in  natural  labour  is  apt  to  occur  when  the  pains  are  very 
strong  and  the  head  very  large,  so  that  the  stretching  of  the  vagina  is 
great  and  comparatively  sudden. 

Situation  nf  vaginal  tears.  —  The  vagina  is  narrowest  at  its  lower  part, 
l)ut  it  is  here  thicker  and  stronger  on  account  of  the  muscles  and  fasciae 
inserted  into  it.  The  median  raphe  of  the  vagina  is  its  thickest  part. 
The  posterior  wall  of  the  vagina  is  longer  than  the  anterior,  and  is  more 
stretched  during  labour ;  for  it  forms  the  outside  of  the  curve  along  which 
the  foetal  head  has  to  pass.  Hence  those  tears  that  depend  on  rigidity 
of  the  tissues,  or  on  large  size  and  sudden  expulsion  of  the  head,  are  most 
often  on  the  posterior  Avail  and  on  one  side,  the  side  being  that  to  which 
the  face  Avas  turned  during  its  passage  through  the  pelvis  (Fig.  122).  The 
position  of  lacerations  due  to  scar  tissue,  or  to  pressure  upon  prominent 
bony  points,  depends  iipon  the  situation  of  those  structural  peculiarities. 

Effects  of  dis2)lacement  of  the  vagina. — When  the  os  uteri  is  fully 
dilated,  and  is  drawn  up  over  the  head,  the  upper  part  of  the  vagina  is 
jmlled  up.  As  the  head  is  driven  down,  it  presses  the  mucous  membrane 
down  before  it.  In  these  two  ways  the  mucous  membrane  may  be  moved 
on  the  submucous  tissue-;  it  may  either  be  pulled  up  or  pushed  down. 

By  such  displacement  of  the  vagina  before  the  advancing  head,  the 
vagina  is  stretched  from  above  dowuAvards;  and  as  tears  by  stretching  are 
transverse  to  the  line  of  greatest  tension,  tears  running  transversely  to 
the  long  axis  of  the  vagina  and  parallel  to  its  orifice  are  thus  produced. 
Tears  of  this  kind  are  generally  near  the  orifice  :  Duncan  estimated  their 
frequency  in  first  labours  at  about  12  per  cent.  Prom  this  movement  it 
follows  that  injuries  of  the  vagina  caused  by  pressure  on  bony  points  are 
not  always  exactly  over  these  bony  points,  but  sometimes  above  them, 
forming  a  sinus  or  pocket  running  doAvnwards  (Fig.  12.'-)).  Another 
consequence  is  that  in  the  displacement  of  the  mucous  membrane  on 
the  submucous  tissue,  vessels  may  be  torn  and  blood  effused  in  quantity 
varying  from  a  few  ecchymoses  up  to  a  quantity  sufiicient  to  form  the 
swelling  of  the  labium  knoAATi  as  thrombus,  or  hcematoma  of  the  vulva. 

Effects  of  iiistrnniental  deliveri/.  —  In  the  ways  above  described  the 
vagina  may  be  torn  during  natural  delivery.  But  lacerations  are  more 
often  prodiiced  directly,  either  by  instruments,  or  by  sharp  edges  or 
])oints  of  bone.  Such  tears  may  be  deep,  and  extend  into  the  bladder, 
ureter,  rectum,  ov  ])eritonenm.      As  a  rule  they  imply  unskilfid  mid- 


43° 


SVSTEJ/   OF  GYNECOLOGY 


wifery ;  either  badly  applied  instruments,  or  pulling  Avrongly  directed. 
But  as.  the  vagina  is  sometimes  torn  in  natural  delivery,  it  is  clear  that 
in  the  cases  in  which  this  is  likely  to  happen,  delivery  in  the  most  skilful 
manner  with  the  most  perfect  instruments,  cannot  prevent  the  accident. 
A  medical  man  is  not,  therefore,  necessarily  deserving  of  censure  because 
the  vagina  was  torn  during  instrumental  delivery.  Injury  to  the  vagina  is 
not  an  inevitable  accompaniment  of  forceps  delivery,  but  it  is  more  likely 
to  happen,  and  to  be  extensive,  if  delivery  is  hastened  by  forceps  than  if 
it  is  left  to  nature. 


Fio.  123.  —  (After  Freund.)    Laceration  of  vagina  forminer  a  "pocket."      A  drainage  tube  has  been 
l)laced  in  the  "pocket."     Krom  nature. 


Iloin  forcpps  delivery  produces  lacerations.  —  Porceps  delivery  adds  to 
the  risk  of  vaginal  laceration  iu  five  ways.  1.  The  blades  of  the  forceps 
increase  by  their  thickness  the  measurement  of  the  mass  traversing  the 
vagina ;  the  vagina,  therefore,  is  a  little  more  stretched,  though  not  much. 
2.  The  forceps  is  used  to  hasten  delivery ;  its  use,  therefore,  generally 
implies  that  the  vagina  is  less  gradually  stretched  than  when  dilatation 
of  the  soft  parts  is  left  to  the  comparatively  slow  action  of  the  natural 
forces.  The  rate  of  progress  is  an  important  factor  in  the  production  of 
vaginal  lacerations.  3.  Unless  the  forceps  exactly  follows  every  movement 
of  the  foital  head,  its  blades  cannot  always  lie  flat  to  the  head;  if  they 
do  not,  then  one  edge  of  each  blade  Avill  be  raiscid  off  the  fa;tal  head. 
Although  this  projecting  edge  is  not  sharp,  yet  the  vagina,  where  it  is 


INJURIES  IN  PARTURITION  431 

pressed  against  this  edge,  is  very  tense,  and  may  be  cut ;  this  is  the 
main  factor  in  the  production  of  forceps  lacerations.  4.  The  curve  of 
the  forceps  is  of  greater  radius  than  that  of  the  head ;  hence  the  vaginal 
stretching  is  not  only  increased  at  the  poles  of  the  diameter  of  the  foetal 
head  at  which  the  forceps  blades  lie,  but  is  enforced  over  a  larger  surface. 
Moreover,  as  I  have  said,  the  head  in  forceps  delivery  is  made  to  move 
on  more  q^iickly,  and  as  the  dilating  agent  advances  down  the  vagina, 
that  canal  must  either  dilate  or  move  on  in  front  of  it.  From  the  in- 
creased volume  and  increased  speed  of  the  dilating  body,  it  results  that 
the  displacement  of  the  vaginal  mucous  membrane  over  the  submucous 
tissues  before  the  advancing  mass,  composed  of  the  head  in  the  grasp  of 
the  forceps,  is  more  than  that  which  is  produced  by  the  head  alone.  The 
bulging  down  of  the  vagina  before  the  advancing  forceps  can  be  seen  in 
any  high  forceps  delivery.  5.  When  the  head  is  delivered  by  artificial 
pulling  the  normal  mechanism  is  interfered  with ;  for  the  accoucheur  can- 
not so  exactly  acquaint  himself  with  the  relations  of  the  head  and  the  pel- 
vis as  to  pull  in  the  precise  direction  and  at  the  precise  moment  which 
will  adapt  the  head  to  the  pelvis  in  the  most  advantageous  manner. 
There  is  often,  therefore,  a  greater  diameter  of  distension  at  a  given  place 
than  in  the  normal  process,  and  in  this  way  the  probability  of  vaginal 
laceration  is  increased.  The  advocates  of  the  axis  traction  forceps  claim 
that  it  lessens  the  risk  of  laceration  of  the  vagina.  With  this  instru- 
ment the  lifting  of  the  edge  of  the  forceps  blade  off  the  head,  and  the 
interference  with  the  natural  mechanisms,  are  lessened ;  but  I  doubt  if 
they  are  done  away  with.  The  other  modes  in  which  forceps  delivery 
favours  laceration  of  the  vagina  remain  the  same  whatever  the  instru- 
ment used. 

Results  of  vaginal  laceration.  —  Tears  of  the  vagina  are  important; 
firstly,  because  they  may  cause  hemorrhage  after  delivery.  The  treat- 
ment of  such  bleeding  is  a  part  of  practical  midwifery,  and  does  not  come 
within  the  scope  of  this  article.  Secondly,  they  make  the  patient  more 
liable  to  puerperal  illness ;  for  every  wound  opens  a  gate  for  the  direct 
entry  of  septic  organisms.  The  presence  of  suppurating  wounds  in  the 
vagina  increases  the  amount  of  the  lochial  discharge,  and  as  wounds  of 
the  vagina  may  form  pockets  (3),  in  which  lochial  discharge  may 
be  retained  and  decompose,  any  active  microbes  present  in  the  pas- 
sages will  multiply  in  them.  These  microbes  may  so  change  the  re- 
tained discharge  that  it  becomes  a  chemical  poison  which  produces 
fever  (saproemia) ;  or  in  successive  generations  they  may  acquire  fresh 
power,  and  produce  septicaemia,  phlebitis,  and  pyaemia ;  or  again  pelvic 
cellulitis. 

Tears  of  the  vagina  may  extend  beyond  the  mucous  luembrane,  and 
injure  the  fasciae  and  muscles  which  form  the  pelvic  floor.  These 
structures  may  indeed  be  injured  without  laceration  of  the  mucous 
membrane ;  or  tears  of  the  mucous  membrane  may  heal,  but  the  injury 
to  the  surrounding  parts  be  imperfectl}^  repaired.  These  injuries  to  the 
muscles  and  fascite  will  be  next  described. 


SYSTEM  OF  GYNECOLOGY 


III.  Injuries  to  the  Muscles  and  Fasciae  of  the  Pelvic  Floor. —  The  fact 
that  pixihipse  of  the  uterus  is  commoner  in  women  who  have  had  children 
than  in  virgins  shows  that  this  condition  is  favoured  by  chikl-bearing.  It 
is  certainly  not  due  to  lacerations  of  the  vaginal  mucous  membrane,  or  of 
the  perineum  ;  for  complete  rupture  of  the  perineum  may  exist  unrepaired 
for  years  without  prolapse.  It  is  therefore  a  reasonable  inference  that 
child-bearing  favours  prolapse  by  causing  injury  to  those  structures  in  the 
pelvic  floor  which  are  the  main  supports  of  the  uterus,  namely,  the  pel- 
vic fasciae  and  the  levator  ani  muscle.  But  our  knowledge  of  these 
injuries  has  not  advanced  beyond  opinion.  I  know  of  no  dissection 
made  to  show  the  existence  of  the  precise  extent  of  such  tears. 

Schatz  has  described  subcutaneous  or  rather  submucous  laceration  of 
the  muscles  forming  the  pelvic  floor  (chiefly  the  levator  ani)  as  occurring 
during  labour.  He  inferred  it  by  feeling,  through  the  vagina,  gaps 
between  the  muscular  bundles,  gaps  which  he  assumed  to  be  produced 
by  the  tearing  through  of  other  bundles  which  ought  to  have  filled 
these  spaces ;  but  he  has  not  verified  this  opinion  by  dissection.  I  have 
felt  gaps  between  the  muscular  bundles  such  as  Schatz  describes,  but 
I  have  failed  to  trace  a  subsequent  tendency  to  prolapse  in  the  patients 
in  whom  I  detected  them.  Skene  has  also  described  subcutaneous  or 
submucous  laceration  of  the  pelvic  floor  during  delivery  Qjresumably 
independently,  for  he  does  not  refer  to  Schatz's  paper,  which  was 
published  about  a  year  previously).  He  describes  not  only  rupture,  but 
fatty  degeneration,  atrophy,  and  paralysis  of  the  torn  muscular  fibres ; 
but  he  does  not  say  that  he  has  verified  either  the  ruptures  or  the  degen- 
eration by  dissection.  He  also  describes  a  change  in  the  position  of  the 
anus  as  a  result  of  injury  to  the  pelvic  floor ;  but  it  does  not  appear 
from  his  paper  that  he  has  compared  the  state  of  the  parts  before  child- 
bearing,  in  any  particular  case,  with  the  state  after  it :  without  such  a 
comparison  it  is  not  possible  to  be  certain  that  Avhat  are  described  as 
changes  due  to  injury  in  child-birth  are  changes  at  all.  Kelly  has 
described  "relaxation"  as  "the  most  important  of  all  injuries  of  the 
perineum  and  pelvic  floor."  His  description  of  the  injuries  is  based 
upon  that  of  Schatz,  but  contains  nothing  to  indicate  that  he  has  veri- 
fied them  by  dissection.  He  says  that  as  a  result  of  these  injuries  the 
anal  cleft  is  no  longer  a  sharp,  deep  furrow,  but  is  flat  and  shallow  ;  and 
tlie  anus  is  set  farther  back  and  more  exposed.  V>\\t  without  knowing 
in  the  individual  cases  what  was  the  condition  of  the  parts  before  child- 
birth, it  is  not  possible  to  be  sure  that  the  peculiarities  mentioned  are 
really  the  result  of  injury.  The  depth  of  the  anal  cleft  depends  princi- 
pally on  the  fatness  of  the  buttocks,  and  the  distance  of  the  anus  from 
the  coccyx  and  pubes  respectively  is  different  in  different  women. 

For  the  reasons  given,  I  l)(!li(;ve  tliat  the  fascia;  and  muscles  of  the 
pelvic  floor  are  often  injured  in  cliild-birth ;  aiid  that  such  injury  is  the 
main  cause  of  uterine  displacements,  notwithstanding  that  the  fa(;t  has 
not  yet  l^een  demonstrated  by  the  exhibition  of  specimens.  These  dis- 
placements are  described  elsewhere  in  this  System. 


INJURIES  IN  PARTURITION  433 

IV.  Rupture  of  the  Perineum.  —  Lacerations  of  the  vagina  are  found 
out  only  by  those  who  look  for  them.  Injuries  to  the  pelvic  floor  are  a 
matter  of  inference,  although  their  existence  is  almost  certain.  Rupture 
of  the  perineum  has  been  known  as  long  as  midwifery  has  been  practised. 

Tears  of  the  vaginal  orifice. — As  the  foetal  head  emerges,  its  stress  falls 
first  upon  the  vaginal,  and  then  upon  the  vulvar  orifice ;  the  vaginal 
orifice  is  marked  by  the  hymen ;  the  posterior  part  of  the  vulvar  orifice, 
which  is  the  part  made  tense,  is  the  fourchette.  The  vaginal  orifice  is 
in  the  nullipara  its  narrowest  part;  consequently  if  any  part  of  the 
vagina  be  torn,  it  is  this.  The  vaginal  orifice  is  always  torn  in  first 
labours.  Such  tears  are  often  multiple  and  stellate,  radiating  from  the 
vaginal  orifice ;  but  wha^tever  other  lacerations  may  take  place  there  is 
always  one  in  the  mesial  line.  Tears  are  more  numerous  on  the  left  than 
on  the  right  side.  If  the  child  is  small  the  tear  may  be  limited  to  the 
vaginal  orifice,  and  not  involve  the  fourchette. 

Tears  of  the  jjerineum.  —  Cases  such  as  those  just  mentioned  are  the 
exception.  In  many  first  labours  (according  to  Duncan  in  60  per  cent) 
the  tear  extends  upwards  through  the  mucous  membrane  of  the  vagina, 
backwards  through  the  skin  of  the  perineum,  and  through  the  tissues  be- 
tween them.  This  is  rupture  of  the  perineum.  If  the  tear  does  not  extend 
through  the  sphincter  ani  it  is  called  "incomplete  rupture."  During 
delivery  the  perineum  is  stretched  both  from  side  to  side  and  from  above 
downwards.  The  tension  of  its  anterior  edge  is  from  side  to  side,  and 
therefore  rupture  here  occurs  in  a  line  perpendicular  to  that  of  greatest  ten- 
sion;  that  is,  from  before  backwards.  When  the  anterior  edge  is  stretched 
till  it  can  stretch  no  more  it  gives  way,  and  the  tear  extends  until  by  it  the 
opening  has  been  made  large  enough  for  the  head  to  pass.  The  extent  of 
the  tear  depends  upon  four  factors ;  these  are,  (i.)  the  elasticity  of  the  tissues ; 
that  is,  the  power  of  the  tissue  elements  so  rearrange  themselves  so  that 
the  part  may  elongate.  Tears  of  the  perineum  are  especially  met  with 
in  elderly  primiparae,  whose  tissues  are  less  elastic  than  those  of  the 
young :  the  difference  dependent  upon  age  is  not  great,  but  it  exists. 
We  know  not  what  the  structural  peculiarities  are  which  make  one 
perineum  more  capal^le  of  stretching  than  another,  (ii.)  The  length 
and  situation  of  the  perineum.  The  length  of  the  perineum  (5)  in  tlu^ 
nullipara  varies  from  five-eighths  of  an  inch  to  two  inches.  The  situation 
of  the  fourchette  varies  from  as  much  as  two  inches  behind  the  lower 
border  of  the  symphysis  pubis,  to  close  up  to  the  symphysis.  It  is  obvious 
that  if  the  perineum  be  short  and  its  anterior  edge  far  back,  less  stretch- 
ing will  be  required  to  let  the  child  pass,  than  if  the  perineum  be  long 
and  its  anterior  edge  far  forward,  (iii.)  The  amount  of  stretching 
required,  or  in  other  words  the  size  of  the  child.  The  birth  of  large 
children  is  oftener  accompanied  with  rupture  of  the  perineum  than  the 
birth  of  small  children.  Of  children  of  average  size  the  head  is  the 
largest  part,  and  therefore  that  which  tears  the  perineum.  But  in 
children  of  excessive  size  the  trunk  is  larger  in  projiortion  to  the  head 
than  in  those  of  average  size ;  therefore  Avith  verv  lar'j^e  children  the 

2  F 


434 


SYSTEM   OF  GYX.-ECOLOGY 


perineum  is  liable  to  be  torn,  or  a  small  tear  to  be  enlarged,  during  the 
passage  of  the  shoulders,  (iv.)  The  suddenness  of  the  stretching.  The 
more  gradual  the  stretching  of  the  perineum  the  less  likely  is  rupture  to 
occur.  Rupture  of  the  perineum  is  especially  apt  to  happen  in  labours 
completed  by  very  strong  uterine  action  (such,  for  instance,  as  is  provoked 
by  ergot),  in  Avhich  case  the  child  is  propelled  quickly  through  the  genital 
canal ;  the  same  occurs  in  labours  assisted  with  forceps  if  the  child  be 
too  rapidly  pulled  through  the  vulvar  orifice.  It  is  not,  however,  a 
necessary  consequence  of  forceps  delivery ;  for  this  can  be  so  managed 
as  to  give  the  perineum  time  to  stretch.  In  labour  protracted  by  weak 
pains,  but  ended  naturally,  rupture  of  the  perineum  seldom  occurs. 


Fig.  lai.  — (After  Eibemont-Dc 


ind  Lepage.)      Central  rupture  of  perineum.      From  nature. 


Central  rnptnre  of  the  pp.rineum.  —  The  common  kind  of  rupture  of  the 
perineum  is  that  which  has  been  described  above  —  a  tear  beginning  at 
the  tense  anterior  edge,  and  extending  backwards.  The  tear  generally 
begins  in  tlie  middle  line,  l>ut,  owing  to  the  vagina  being  thicker  in  the 
median  raphe,  an  extensive  tear  seldom  keeps  the  middle  line. 

There  are  less  common  ways  in  whicli  ruptiu-e  occurs.  One  way  is  called 
central  rupture  (Fig.  124):  in  this  form  the  tear  begins  in  the  posterior  wall 
of  the  vagina,  above  the  orifice ;  then  as  the  head  is  forced  on,  it  presses 
into  the  tear  in  the  vagina,  widens  it,  presses  asunder  the  muscular  and 
fibrous  stru(;tures  of  tlie  perineal  body,  bulges  down  the  skin  in  the 
middle  of  the  perineum,  and  finally  tears  it.  The  tear,  thus  begun  in 
the  niid(ll(!  of  the  periiunuii,  may  extend  forwards  to  the  f ourchette and 


INJURIES  IN  PARTURITION  435 

backwards  to  the  anus  —  central  rupture  thus  becoming  complete  rupture. 
Such  I  believe  to  be  the  common  mode  of  production  of  central  rupture 
of  the  perineum.  But  a  tear  of  the  vagina  and  cellular  tissue  of  the 
perineum  may  not  involve  the  skin  of  the  perineum ;  the  skin  of  the 
perineum  may  be  centrally  split  without  injury  to  the  mucous  membrane 
of  the  vagina ;  and  the  cellular  tissue  of  the  perineum  may  be  torn 
without  tear  of  either  vaginal  mucous  membrane  or  perineal  skin.  The 
formation  of  a  central  perforation  may  begin  in  any  one  of  these  ways, 
the  order  of  tearing  being  not  always  the  same.  Children  have  been 
born  through  central  rupture  of  the  perineum  Avithout  injury  to  either 
anus  or  fourchette  (10) ;  although  I  think  (wdth  Madame  Lachapelle 
and  Matthews  Duncan)  that  it  is  more  common  for  delivery  to  take  place 
through  the  vaginal  orifice  even  in  the  presence  of  a  central  rupture. 

Rupture  from  above  cloiv7iwards.  — There  is  a  still  rarer  mode  of  rupt- 
ure of  the  perineum  which  I  have  once  seen.  The  recto-vaginal  septum 
was  first  torn  through,  and  then  this  tear  extended  downwards  through 
the  perineum.  After  the  head  had  been  delivered  the  hand  protruded 
through  the  amis,  and  then  the  shoulder  came  down,  tearing  the  perineum 
from  above  downwards.  Such  a  rupture  must,  of  course,  always  be  com- 
plete.    This  mode  of  rupture  has  also  been  reported  by  Baudry. 

Healing  of  perineal  rupture.  —  If  left  untreated,  incomplete  rupture 
of  the  perineum  usually  unites  through  part  only  of  its  extent,  by  the 
union  of  granulations  on  opposite  sides ;  so  that  the  perineum  remains 
shorter  than  it  was  before.  Complete  rupture  of  the  perineum  occasion- 
ally heals  without  treatment ;  but  this  is  an  exceptional  event. 

Results  of  rupture  of  perineum.  —  Complete  rupture  of  the  perineum 
deprives  the  patient  of  the  power  of  retaining  faeces  in  the  rectum.  If 
a  few  fibres  of  the  sphincter  ani  remain  intact,  so  that  its  power  is  not 
destroyed,  but  only  weakened,  the  patient  may  be  able  to  retain  scybala, 
but  unable  to  retain  fluid  faeces. 

Incomplete  rupture  of  the  perineum  enlarges  the  vaginal  orifice. 
The  consciousness  of  being  "  more  open"  is  sometimes  disagreeable  to  the 
patient.  If  the  patient  suffer  from  descent  of  the  uterus  or  vagina,  for 
which  the  support  of  a  pessary  is  desirable,  the  shortening  of  the  perineum 
may  make  it  difficult  or  impossible  to  get  a  vaginal  pessary  retained. 

Neither  complete  nor  incomplete  rupture  of  perineum  can  cause  pro- 
lapse of  the  uterus.  I  have  seen  a  patient  Avhose  perineum  had  been 
ruptured  twenty  years  before,  in  her  first  and  only  confinement,  who 
had  suffered  since  from  inability  to  retain  her  fieces,  yet  she  had  not 
the  slightest  prolapse.  But  in  the  way  above  described  rupture  of  the 
perineum  much  affects  the  success  of  the  mechanical  treatment  of  the 
prolapse.  Central  rupture  of  the  perineum  may  heal  incompletely, 
leaving  a  fistulous  channel  betAveen  the  vagina  and  the  perineum. 
Madame  Lachapelle  thought  such  fistula  to  be  its  usual  consequence. 
That  such  fistulas  are  seldom  noAV  seen  is  a  gratifying  illustration  of 
the  progress  of  obstetric  surgery. 

Treatment.  —  There  is  only  one  treatment  of  rupture  of  the  iierineum, 


436  SYSTEM   OF   GYXjECOLOGY 

and  that  is  a  plastic  operation.     The  description  of  the  operation  is  not 
Avithin  the  scope  of  this  article. 

I  come  now-  to  describe  the  injuries  produced  by  crushing. 

Mechanicai.     Injuries  —  B.      Crushing.  —  Vaginal      Fistulas.  — 

Vaginal  fistulas  are  among  the  most  distressing  consequences  of  mis- 
managed labour.  There  are  three  ways  in  which  such  fistulse  may 
be  formed :  (1)  By  tearing.  The  tears  in  the  vagina  Avhich  have  been 
described  in  the  foregoing  pages  may  be  so  deep  and  extensive  as  to 
open  the  bladder  or  the  rectum,  and  then,  if  healing  be  imperfect,  a 
fistula  is  left.  This  is  the  usual  way  in  which  recto-vaginal  fistula  is 
formed,  but  it  is  a  rare  mode  of  production  of  vesical  fistulee.  (2)  By 
perforation,  that  is,  by  a  sharp  instrument  or  point  of  bone  being 
thrust  through  the  vagina  into  the  bladder  or  rectum.  This  is  a  rare 
mode  of  origin  of  fistulas  of  any  kind.  Fistulas  formed  either  by 
tearing  or  perforation  have  this  feature  in  common,  that  the  symptoms 
they  cause  appear  immediately  after  delivery.  (3)  By  sloughing. 
Nineteen  out  of  twenty  vesical  fistulas  are  produced  in  this  way. 
When  so  produced,  symptoms  do  not  appear  immediately  after  delivery, 
but  are  postponed  till  after  the  separation  of  the  slough.  The  slough- 
ing comes  of  continuous  compression  of  soft  tissues  between  the  foetal 
head  and  the  pelvic  bones :  such  compression  takes  place  when  the 
membranes  have  ruptured,  the  amniotic  fluid  has  drained  away,  the 
uterus  has  passed  into  a  state  of  tonic  contraction,  and  there  is  such  a 
disproportion  between  the  foetal  head  and  the  pelvic  brim  or  cavity 
that  the  head  cannot  enter  the  one  or  pass  through  the  other.  If  the 
head  cannot  enter  the  brim,  the  uterine  force  is  exerted  in  compressing 
the  soft  parts  nipped  between  the  head  and  the  most  prominent  points 
of  the  jjelvic  brim.  In  the  ordinary  form  of  contracted  pelvis  the 
most  jn-ominent  points  are  the  sacral  promontory  and  the  pubic  sym- 
physis ;  the  pressure  effects  are  therefore  greatest  opposite  those  points. 
If  the  pressure  be  so  great  as  to  kill  the  nipped  tissues,  they  slough. 
This  sloughing  is  produced  not  by  the  magnitude  of  the  pressure,  but 
by  its  long  continuance  without  intermission.  The  after-effects  of  the 
sloughing  depend  upon  the  situation  of  the  damage. 

Crushing  of  tissues  opposite  sacral  promontory.  — The  vaginal  wall,  or 
the  cervix  uteri,  may  slough  where  there  has  been  compression  between 
the  head  and  the  sacral  promontory,  and  such  slouglung  may  o])en  the 
poucVi  of  Douglas.  If  tlie  parts  are  preserved  from  septic  infection  the 
slough  is  separated,  and  Douglas'  ])0uch  is  closed  by  adhesive  inflamma- 
tion. Such  adhesions  may  alter  the  position  of  the  uterus,  and  some 
physicians  think  that  such  changes  in  the  position  of  the  uterus  produce 
ulterior  harmful  eifects.  Information  upon  this  jwint  will  be  found  in 
the  article  upon  "Displacements  of  the  Uterus." 

Crushing  of  tissues  opposite  the  syw,/>hi/sis  pubis.  —  Sloughing  in  this 
situation  is  more  important  tlian  in  any  other,  Ixicause  here  it  destroys 
the  integrity  (jf  the  urinary  ])assages.     The  tissues  which  suffer  most 


INJURIES  IN  PARTURITION 


437 


are  those  nearest  the  head,  that  is,  the  posterior  wall  of  the  urinary 
canal ;  and  therefore  the  result  of  such  sloughing  is  incontinence  of 
urine. 

Situations  of  urinary  Jist  alas.  —  The  place  at  which  the  sloughing  takes 
place  depends  upon  the  extent  to  which  the  os  uteri  had  been  dilated  and 
pulled  up  over  the  head  at  the  time  pressure  became  continuous  (Fig.  125). 
Sometimes,  although  very  rarely,  the  membranes  rupture  early,  and  the  os 
uteri  dilates  slowly,  so  that  the  amniotic  fluid  has  drained  off,  and  pressure 
has  become  continuous  before  the  bladder  has  been  pulled  up  out  of  the 
pelvis.  In  this  case  the  slough  may  involve  the  cervix  uteri  and  the 
ureter,  a  uretero-cervical  fistula  being  formed.  (These  are  often  spoken 
of  as  "  uretero-uterine  fistulas,"  but  the  sloughing  affects  the  cervix,  not 


Cervico-vesica] 


Vcsico-vaginaL-— -" 


Urclhro-varinaL-- 


Rocto-va~inal. 


Fig.  125.  — (After  de  Sinct>  )     Dufriam  <iho^Mng  different  kinds  of  fistula. 

the  body  of  the  uterus.)  One  or  both  ureters  may,  in  consequence  of 
sloughing,  come  to  open  into  the  fistula.  It  must  be  admitted  as  possi- 
ble that  the  tissues  killed  by  pressure  may  comprise  the  ureters,  and  not 
the  bladder  ;  but  the  most  probable  explanation  of  such  cases  is  that  the 
slough  involved  cervix,  ureters,  and  bladder  Avail ;  and  that,  while  the 
urine  was  flowing  away  through  the  cervix,  the  gap  in  the  bladder 
healed  by  granulation.  No  uretero-cervical  fistula  has  yet  been  dissected 
after  death.  If  there  is  a  persistent  hole  in  the  bladder  as  well  as  the 
destruction  of  part  of  the  ureters  and  cervix,  the  condition  is  called 
vesico-cervical  (or  incorrectly  vesico-uterine)  fistula.  The  destruction  of 
tissue  may  involve  a  large  part  of  the  cervix  uteri  and  the  vagina ;  and 
this  state  is  called  vesico-cervico-vaginal  (or  vesico-utei'o-vaginal)  fistula. 
Fistulas  involving  the  cervix  uteri  nre  rare;  according  to  Xeugebauer 
they  form  about  8  per  cent  of  the  vesical  fistuk>?  which  follow  delivery  : 


43S 


SYSTEM   OF  GYNECOLOGY 


listulas  involving  the  nreter  are  still  rarer ;  they  are  rare,  because  press- 
ure during  delivery  seldom  becomes  continuous  until  after  the  cervix 
uteri  has  been  pulled  up  out  of  the  pelvic  cavity.  When  at  this  latter 
stage  of  the  labour  pressure  becomes  continuous,  the  bladder  wall  is 
killed  at  the  part  where  it  is  in  relation  with  the  vagina,  and  a  vesico- 
vaginal fistida  is  the  injury  which  results. 


Fio.  12fi. — (After  Martin.)     Annular  sloufjliiiif,' of  ooi-vix  uteri.     From  nature.     Upper  surface. 

It  is  possible  that  during  laljour  the  relation  of  parts  may  alter,  or  be 
interfered  with,  so  that  after  part  of  the  cervix,  ureters,  and  bladder  have 
been  so  compressed  as  to  kill  the  tissues,  the  cervix  may  be  pulled  up, 
and  continuous  pressure  come  to  be  exerted  on  the  bladder;  thus  two 
fistulas,  a  vesico-cervical  and  a  vesico-vaginal,  are  formed.  The  more 
probable  explanation  of  tlie  co-existence  of  two  fistulas  is  that  the  slough- 
ing at  first  jjrodiiced  one  large  gap,  Init  that  across  this  s^\\\)  a  bridge  of 
tissue  has  suliseqnfuitly  united.  Cervical  fistulas  according  to  Neuge- 
bauer  are  more  common  in  multipara;  than  in  primiparjje. 

Annular  sloughing.  —  In  cases  in  which  the  pelvis  is  contracted  in  all 


INJURIES  IN  PARTURiriON 


439 


its  dimensions,  or,  being  normal  in  shape  and  size,  the  child's  head  is  too 
large,  the  head  may  enter  the  pelvic  cavity  and  become  impacted  there; 
that  is  to  say,  stuck  fast,  unable  either  to  advance  or  to  recede.  If  this 
happen,  a  ring  of  soft  tissue  where  the  head  is  in  contact  with  the  pelvis 
will  be  crushed  all  round.  If  the  impaction  take  place  before  the  dilatation 
of  the  OS  uteri  is  complete,  the  cervix  uteri  may  have  its  vascular  supply 
cut  off  by  the  crushing  of  a  ring  of  tissue  above  it,  and  may  consequently 
slough.     This  sloughing  may  affect  only  a  ring  of  cervical  tissue,  and,  if 


V^-- 


FiQ.  127. — (After  Martin.)    Annular  sloufrhing  of  cervix  uteri.     From  nature.     Lower  surface. 

SO  limited,  the  ill  effects  do  not  outlast  the  puerperium  (Figs.  12G  and  127). 
But  the  killing  of  tissue  by  pressure  may  affect  more  than  the  cervix ;  it 
may  involve  also  the  upper  part  of  the  vagina  and  the  base  of  the  bladder. 
When  healing  has  taken  place,  so  far  as  it  may  after  separation  of  such 
a  slough,  the  vagina  is  found  converted  into  a  short  funnel  ending  in 
scar  tissue  bounding  a  hole  not  large  enough  to  admit  the  finger.  I  have 
recorded  a  case  in  which  such  sloughing  (5)  took  place  in  a  woman  who 
was  not  pregnant :  in  that  case  I  was  not  able  to  find  out  its  cause. 
The  slough  is  preserved  in  the  London  Hospital  Museum  (Fig.  128) 


440 


SYSTEM   OF  GVX.-ECOLOGY 


(2123).  I  liave  seen  a  case  iu  which  sloughing  took  place  after  delivery, 
and  the  resulting  condition  was  exactly  the  same  as  in  the  case  above 
referred  to;  therefore,  although  the  slough  "was  not  preserved,  I  do  not 
doubt  that  the  same  parts  were  involved. 

Symjiloms. — The  symptom  of  a  vesical  fistula,  wherever  situated  and 
of  whatever  size,  is  incontinence  of  urine ;  that  is,  the  patient's  urine 
continually  runs  aAvay  through  the  vagina.  The  only  exception  to  this 
is  that  when  the  fistula  is  small  the  pressure  of  the  vaginal  wall  against 
it  will  sometimes  temporarily  close  it  while  there  is  not  much  urine  in 
the  bladder,  and  the  patient  is  recumbent.  Hence  these  patients  some- 
times say  that  they  can  retain  the  urine  for  a  time  while  lying  down. 
The  presence  of  a  fistula  is  suggested,  and  may  almost  be  affirmed  by 
the  urinous  smell  of  the   patient's   clothing,  before   its    discovery  on 


()s  uteri  extermnn. 


Fig.  12S.  —  Slough  in  one  mass  of  oorvix  uteri,  upper  part  of  vagina,  and  base  of  bladder.    From  a  speci- 
men in  the  London  Hospital  Museum.     No.  2128.     Natural  size.     (Drawn  by  Dr.  J.  H.  Sequeira.) 

examination.  Incontinence  of  urine  is  not  the  same  thing  as  irritation 
of  the  bladder,  that  is,  frequent  micturition  ;  although  in  both  the  patient 
may  describe  her  trouble  as  inability  to  retain  urine.  When  there  is 
merely  irritation  the  patient  can  generally  eni^jty  the  bladder  often 
enough  to  prevent  her  clothing  from  being  more  tlian  occasionally  wetted ; 
but  when  there  is  incontinence  this  is  impossible,  and  unless  special  pro- 
vision be  made  the  clothes  become  saturated. 

History.  —  When  a  fistula  has  been  formed  in  tlu;  usual  way  —  that  is, 
by  sloughing  of  the  i)arts  from  pressure  — there  is  no  inc(mtinence  until 
tiie  slough  has  at  some  part  separated.  Hence  the  history  will  bo  that 
the  patient  had  a  long  labour,  but  no  incontinence  of  urine  till  from  five 
to  ten  days  afterwards  fwliich  is  th(!  usual  time  for  the  se])aration  of  the 
sloughj,  or  even  later ;  and  that  then  the  urine  began  to  run  away  in- 


INJURIES  IN  PARTURITION  441 

voluntarily.  If  the  fistula  was  produced  by  tearing  or  by  perforation 
the  incontinence  of  urine  will  date  from  delivery. 

Diagnosis.  —  This  can  only  be  finally  made  by  physical  examination. 
Put  the  patient  on  her  side,  and  expose  the  cervix  and  vagina  with  a 
duck-bill  speculum  ;  if  there  be  a  vaginal  fistula  the  opening  will  be  seen. 
Vaginal  fistulas  are  often  large  ;  and  then  the  mucous  membrane  of  the 
opposite  vesical  wall  often  bulges  through  the  fistula,  forming  a  rugous 
swelling  of  deeper  red  and  more  velvety  feel  than  the  vaginal  wall. 
Cervical  fistulas  are  generally  small;  a  cervical  fistula  big  enough  to 
admit  the  finger  is  exceptional. 

If  when  the  cervix  and  vagina  are  exposed  a  fistula  cannot  be  seen, 
and  yet  there  is  no  doubt  that  urine  continually  escapes  by  the  vagina, 
put  a  catheter  in  the  urethra  and  inject  milk  into  the  bladder.  If  there 
be  a  very  small  vaginal  fistula  the  white,  conspicuous  jet  of  milk  escaping 
through  it  will  mark  its  place.  If  the  fistula  be  cervical  the  milk  will 
come  back  through  the  cervix  uteri.  If  the  fistula  be  uretero-cervical  on 
one  side,  the  history  will  be  that  the  urine  flows  continually  away  by 
the  vagina,  while  yet  some  urine  is  passed  naturally;  and  when  milk  is 
injected  into  the  bladder  none  Avill  flow  into  the  vagina.  A  cervical 
fistula  involving  both  ureters  is  characterised  by  the  flow  of  all  the  urine 
through  a  vagina  which,  on  examination  by  injection  of  milk,  shows  no 
passage  from  the  bladder  to  the  vagina. 

Usual  concomitants.  — With  a  fistulous  opening  into  the  bladder  there 
is  generally  more  or  less  severe  cystitis,  so  that  the  urine  is  ammoniacal 
and  ropy.  Injury,  severe  enough  to  cause  sloughing  of  the  bladder 
wall,  often  leads  to  sloughing  at  other  parts  of  the  genital  canal,  and  to 
pelvic  irLtiammation;  hence  there  is  often  fixation  of  the  parts  by  parametric 
exudation  and  by  contraction  of  the  vagina  by  scar  tissue  at  other  places. 
The  irritation  of  the  urine  causes  inflammation  of  the  skin  of  the  labia 
and  thighs  ;  and  the  mucous  membrane  and  skin  are  often  encrusted  with 
earthy  salts. 

Relation  to  operative  delivery. — When  inquiry  is  made  as  to  the  labour 
after  which  a  fistula  has  formed,  it  is  found  in  most  cases  that  some 
abnormal  condition  was  present ;  and  in  many  that  operative  delivery 
was  required.  Complications  are  frequent  in  such  labours,  because  the 
disproportion  which  leads  to  continuous  pressure  also  leads  to  disturbance 
of  the  mechanism  of  labour.  There  is  no  special  complication  other  than 
disproportion,  which  produces  sloughing  and  fistula  as  its  consequence. 
The  public  are  apt  to  think  that  the  fistula  Avas  produced  by  the  operative 
delivery,  and  it  is  true  that  in  a  few  cases  fistula  is  thus  produced.  In 
the  great  majority  of  cases,  however,  — those  in  which  the  fistula  is  pro- 
duced by  sloughing,  —  the  fault  lay  not  in  the  interference  with  natural 
delivery,  but  in  the  undue  postponement  of  operative  delivery.  It 
is  hardly  necessary  to  point  out,  however,  that  delay  in  giving  aid  is  not 
always  the  fault  of  the  medical  attendant. 

Treatment.  — The  curative  treatment  of  a  urinary  fistula  is  its  closure 
by  a  plastic  operation.     The  description  of  these  operations  is  beyond 


442  SYSTEM  OF  GYNAECOLOGY 

the  scope  of  this  article.  [  Vide  art.  "  Plastic  Gynsecological  Opera- 
tions."] 

The  palliative  treatment  consists  in  the  constant  use  of  some  appliance 
to  receive  the  urine.  While  the  patient  is  about  the  choice  lies  between 
a  urinal,  and  absorbent  pads  frequently  changed.  The  latter  is  the  least 
disagreeable.  Wood  wool  is  the  best  absorbent  material.  The  pads 
must  be  thicker  than  is  required  for  the  menstrual  discharge,  and  must 
be  changed  often.  If  the  patient  be  so  situated  that  she  must  go  for 
hours  without  the  opportunity  of  changing  the  pads,  she  must  wear  a 
urinal  —  an  appliance  which  consists  essentially  of  a  trough  to  receive  the 
urine,  whence  it  is  conducted  by  a  narrow  tube  to  a  bag.  There  are 
practically  only  two  kinds  :  one  in  which  the  trough  is  made  rigid,  so 
that  it  keeps  its  shape,  though  its  pressure  may  be  irksome ;  the  other 
(known  as  the  French  model)  in  which  the  trough  is  made  of  thin 
flexible  india-rubber:  the  latter  is  the  less  uncomfortable.  At  night 
discomfort  is  reduced  to  a  minimum  if  the  patient  sleep  on  what  is  known 
as  a  "  fracture  bed  "  (that  is,  one  with  an  opening  in  the  middle  for  a 
pan),  and  is  provided  with  plenty  of  absorbent  material. 

It  is  best  to  postpone  operation  until  at  least  two  months  after 
delivery,  and  this  for  two  reasons  :  firstly,  the  parts  become  less  vascular 
and  the  tissues  firmer  after  involution  is  complete,  both  of  which  changes 
are  conducive  to  success  in  the  operation ;  secondly,  a  vesical  fistula,  either 
cervical  or  vaginal,  may  spontaneously  close.  This  is  more  likely  to 
happen  in  the  case  of  a  cervical  fistula,  because  such  fistulas  are  small ; 
but  I  have  known  a  vaginal  fistula,  big  enough  to  admit  several  fingers, 
to  close  completely  without  operation. 

Recto-varj'utal  fistula,  that  is,  an  opening  between  the  rectum  and  the 
vagina,  is  seldom  produced  by  sloughing;  because  at  the  pelvic  brim,  the 
place  where  the  tissues  are  most  often  nipped  and  made  to  slough,  the  rec- 
tum is  at  the  side  of  the  sacral  promontory,  and  therefore  out  of  the  way 
of  pressure.  Such  a  fistula  is  generally  the  result  of  incomplete  union 
of  a  bad  rupture  of  the  perineum,  —  the  lower  part  of  the  rent  heals,  the 
upper  does  not.     These  fistulas  are  seldom  large. 

A  recto-vaginal  fistula  permits  the  involuntary  escape  of  faeces  and 
flatus  from  the  rectum  into  the  vagina.  They  are  curable  by  a  plastic 
operation,  and  in  no  other  way. 

Morbid  Involution 

Subinvolution  means  that  the  involution  of  the  uterus  after  delivery 
has  not  been  complete.  To  give  a  proper  account  of  this,  it  is  necessary 
first  to  describe  briefly  the  normal  process  of  involution. 

TJie  involution  of  the  uterus.  —  On  the  day  after  delivery  the  uterus 
weighs  from  a  pound  and  a  half  to  two  pounds  and  a  half ;  and  its  fundus 
reaches  as  liigh  as  the  umbilicus.  Its  return  during  the  lying-in  period 
nearly  to  the  dimensions  it  had  before  pregnancy,  is  called  "  the  involu- 
tion of  the  uterus."     Generally  by  the  twelfth  day  after  delivery  the 


INJURIES  IN  PARTURITION  443 

fundus  uteri  is  no  longer  above  the  pelvic  brim.  Two  weeks  after 
delivery  the  uterus  weighs  about  half  a  pound ;  and  three  weeks  after 
delivery  from  four  to  six  ounces.  Involution  is  in  most  cases  complete  at 
the  end  of  two  months,  sometimes  at  the  end  of  a  month  ;  but  sometimes 
it  takes  as  long  as  three  months. 

Iloxf^  involution  is  effected. — We  have  no  exact  knowledge  of  the  changes 
which  take  place  in  the  peritoneal  covering  of  the  uterus.  It  becomes 
smaller,  and  the  wrinkles  present  in  it  after  delivery  are  smoothed  away; 
this  is  all  we  know.  It  is  stated  in  most  text-books  that  the  muscular 
fibres  of  the  pregnant  uterus  undergo  fatty  degeneration  during  the  lying- 
in  period  and  are  thus  removed,  new  ones  being  formed  in  their  stead. 
The  alleged  fatty  degeneration  rests  upon  observations  by  Kolliker, 
supported  by  those  of  Luschka,  Sanger,  and  Ma}' or ;  but  it  has  been 
denied  by  Kobin.  The  opinion  that  the  old  muscular  fibres  are  destroyed 
and  new  ones  developed,  was  originated  by  Kilian  in  1849.  His  state- 
ments were  based  on  very  few  observations :  most  of  them  were  on  the 
uteri  of  women  who  had  died  from  disease,  and  were  made  after  decom- 
position had  begun ;  moreover,  at  the  time  they  were  made  histology  was 
in  its  infancy.  The  subject  has  been  more  recently  studied  by  Dr.  T. 
A.  Helme,  with  the  advantage  of  modern  histological  methods.  He 
observed  the  process  in  the  rabbit,  and  examined  many  specimens  im- 
mediately after  death,  and  at  all  stages  of  the  process  of  involution.  His 
results  far  outweigh  the  few  and  imperfect  observations  quoted  in  support 
of  the  text-book  account.  Helme  finds  no  fatty  degeneration.  There  is 
atrophy,  that  is,  diminution  in  volume  of  the  muscular  fibres.  There  is 
not,  as  in  a  pathological  atrophy,  degeneration  of  the  muscular  fibres  and 
increase  of  connective  tissue,  but  a  shrinking  of  muscle  and  connective 
tissue  alike  —  a  physiological  retrogression.  The  change  is  probably 
chemical,  a  sort  of  peptonisation  which  makes  the  contents  of  the  muscle 
cells  more  soluble,  so  that  they  can  pass  into  the  lymph  stream ;  but  there 
is  no  fatty  change.  The  atrophy  goes  on  simultaneously  and  equally  at  all 
parts  of  the  uterus  alike ;  no  groups  of  degenerated  cells  are  found  amidst 
healthy  tissues.  Helme  has  noticed  two  stages  in  the  process  :  during 
the  first  thirty-six  hours  the  muscular  fibres,  which  at  the  end  of 
pregnancy  are  remarkably  translucent,  become  cloudy  and  rapidly 
diminish  in  volume ;  then  a  more  gradual  shrinking  follows.  Helme 
finds  no  evidence  of  a  destruction  of  old  fibres,  or  of  a  formation  of 
new  ones.  The  only  change  seems  to  be  that  large  fibres  become 
small.  Broers  has  investigated  the  subject  in  the  same  way  as  Helme, 
and  finds  fatty  degeneration.  Helme  tells  me  he  thinks  that  the 
granules  which  Broers  takes  for  fat  globules  are  not  such :  in  support  of 
his  opinion  he  points  out  that  Broers  found  them  in  blood  corpuscles, 
a  place  where  fat  globules  would  hardly  be  expected,  and  in  the  uterus 
during  labour. 

Observations  are  also  discrepant  as  regards  the  changes  in  the 
connective  tissue.  Fatty  degeneration,  atrophy,  development  of  new 
connective  tissue,  have  each  been  described.     Helme  finds  that  the  con- 


444  SYSTEM   OF  GYNECOLOGY 

nective  tissue  at  first  becomes  granular,  and  then  gradually  diminishes 
and  dissappears. 

During  the  last  few  days  of  pregnancy  and  the  first  few  days  of 
involution  giant  cells  with  many  nuclei  are  to  be  seen :  they  are  formed 
by  the  coalescence  of  single  cells  which  are  probablj^  leucocytes.  These 
giant  cells  are  not  seen  after  the  sixth  da}'  of  involution.  Their  function 
is  probably  to  eat  up  the  waste  material  lying  about  them  —  granules 
from  connective  tissue  or  matter  in  solution  from  muscle  cells. 

Structural  changes  take  place  also  in  the  vessels.  At  the  beginning 
of  involution  the  veins  are  compressed  by  the  contraction  of  the  muscular 
bundles  between  which  they  lie  :  some  of  them  become  pervious  again ; 
in  others,  their  endothelium  comes  to  present  a  hyaline  and  granular 
appearance,  and  the  vessel  is  gradually  obliterated  and  disappears.  In 
some  of  the  veins  there  is  a  proliferation  of  the  intima,  so  that  the  vessel 
wall  becomes  permanently  thickened.  In  some  of  the  arteries  there  is  a 
hyaline  and  granular  appearance  of  the  coats :  some  become  obliterated, 
but  in  the  larger  ores  there  is  a  tri^e  proliferative  endarteritis,  growth 
taking  place  both  from  the  endothelium  and  from  the  sub-endothelial 
connective  tissue.  At  the  end  of  involution  the  connective  tissue  around 
the  arteries  is  increased  in  quantity,  the  arterial  muscular  Avail  is  greatly 
hypertrophied,  and  the  inner  wall  considerably  thickened.  On  section 
the  arteries  project  beyond  the  surrounding' surface,  and  present  thick, 
yellowish  white  walls,  more  opaque  than  the  tissues  around.  This 
state  of  the  arteries  was  described  by  Sir  J.  Williams  in  1882  (15).  He 
holds  that  it  affords  ''  the  strongest  presumptive  evidence  of  parity  " 
that  we  possess. 

In  an  ideal  case  involution  should  go  on  till  the  uterus  is  reduced  to 
the  same  size  as  it  was  before  pregnancy ;  this,  however,  seldom  occurs. 
It  is  so  common  for  involution  to  be  not  quite  complete  that  in  text-books 
of  anatomy  it  is  stated  that  the  parous  uterus  is  normally  larger  than 
the  virgin  uterus.  When  involution  is  thus  incomplete  the  condition  of 
the  uterus  is  called  "subinvolution."  In  a  few  cases  the  involution 
goes  on  to  such  a  degree  tliat  the  uterus  becomes  smaller  than  it  was 
before  pregnancy.  This  is  called  "  superinvolution  "  or  "  puerperal 
atrophy  of  the  uterus." 

77te  morbid  anatomy  of  subinvolution.  —  We  know  of  no  couvstant 
difference,  except  in  size,  between  uteri  which  a  few  months  after  delivery 
still  remain  large,  and  those  which  have  returned  to  the  ordinary  size 
of  the  unimpregnated  uterus.  General  enlargement  of  the  uterus  with 
pelvic  pain  and  other  symptoms  is  known  as  "chronic  metritis,"  and  some 
writers  have  described  subinvolution  and  chronic  nu;tritis  as  identical. 
General  enlargement  of  the  uterus  j)ersisting  long  after  delivery  was 
fles(;ribed  Ity  Kleits  under  the  name  of  "diffuse  liyper])lasia  of  the 
uterine  parenchyma."  He  says  that  in  some  cases  hypertrophy  of  the 
muscular  fibres  is  present ;  in  others,  hypertrophy  of  the  connective  tissue 
V)undles.  The  more  the  latter  are  developed  the  firmer  the  tissue. 
He  says  that  this  hypertrophy  has  been  regarded  as  a  result  of  chronic 


INJURIES  ly  PARTURITION  445 

inflammation,  and  that  in  many  cases  inflammatory  changes  in  the  mucous 
membrane  are  unquestionably  present;  in  many  others,  however,  there  is 
no  clinical  proof  of  inflammation  having  been  present,  the  condition  having 
developed  itself  without  any  symptoms  \y\d.  sect,  on  Fibrous  Hyperplasia 
in  Prof.  Adami's  art.  on  "Inflammation  "  intlie  System  of  Medicine,  vol.  i., 
and  also  Dr.  Mott's  art.  in  same  volume].  Both  inflammatory  and  non- 
inflammatory forms  have  in  common  the  enlargement  of  the  uterus  and 
increase  in  its  blood-supply.  Klob  described  chronic  enlargement  of 
the  uterus  as  being  due  to  a  diffuse  growth  of  connective  tissue.  He  said 
that  the  uterus  is  at  first  congested  and  turgid,  the  connective  tissue 
being  immature ;  but  that  the  longer  the  disease  lasts  the  denser  the 
fibrous  tissue  becomes,  compressing  and  perhaps  obliterating  the  vessels, 
and  making  the  uterine  tissue  paler  and  harder.  At  the  beginning  of  the 
process,  according  to  Klob,  the  muscular  fibres  are  hypertrophied ;  but 
later  they  are  lost  in  the  hypertrophy  of  the  connective  tissue.  The 
uterus  when  so  enlarged  has  all  its  diameters  increased,  but  especially  the 
antero-posterior  measurement  of  the  uterine  body.  The  cervix  is  thick- 
ened. The  uterine  cavity  is  longer  and  broader,  but  its  anterior  and  pos- 
terior walls  are  still  almost  in  contact.  Klob  holds  that  the  pathological 
change  is  not  a  result  of  inflammation,  but  a  growth  of  connective  tissue. 
Klob  does  not  say  how  far  his  conclusions  are  based  on  the  writings  of 
others,  and  how  far  on  specimens  examined  by  himself ;  nor  does  he  say 
how  many  specimens  he  has  examined,  or  from  what  women  obtained. 
Without  some  knowledge  of  the  age,  the  time  intervening  since  the  last 
pregnancy,  the  cause  of  death,  and  the  associated  morbid  conditions  in 
the  pelvis,  it  is  impossible  to  decide  how  far  the  changes  described  by 
Klob  are  such  as  naturally  occur  in  healthy  Avomen  as  they  grow  older, 
or  how  far  they  are  morbid. 

The  causes  of  subinvolution}  —  For  perfect  involution  of  the  uterus 
to  take  place,  it  is  necessary  that  during  the  Ijdng-in  period  the  patient 
should  be  healthy  and  the  uterus  contracted.  The  contractions  of  the 
uterus,  by  intermittently  compressing  the  vessels,  mechanically  help 
the  circulation  both  of  blood  and  lymph  through  the  organ.  When  the 
uterine  contractions  are  imperfect,  the  more  languid  movement  of  the 
blood  helps  to  make  involution  slow  and  incomplete.  Therefore,  after 
post-partum  haemorrhage  —  an  accident  which  implies  imperfect  uterine 
contraction  —  subinvolution  is  apt  to  appear.  Uterine  contraction  is  es- 
pecially imperfect  when  a  bit  of  placenta  or  membrane  is  retained.  The 
presence  of  what  (in  the  lying-in  period)  is  a  foreign  body  in  the  uterus, 
not  only  interferes  with  uterine  contractility,  but  mechanically  prevents 
the  shrinking  of  the  organ.  When  fever  arises  all  the  bodily  functions- 
are  badly  performed,  and  the  natural  metabolism  is  altered ;  the  uterus, 
like  other  tissues,  then  suffers,  and  its  involution  is  retarded.  This  effect 
is  especially  marked  when  the  cause  of  the  fever  is  inflammation  in  the 
l)elvis  ;  for  then  the  uterus  not  only  suffers,  in  common  with  the  rest  of  the 

1  For  an  analysis  of  what  has  been  done  on  this  subject  and  original  observations,  see 
References  (10)  and  (11). 


446  SYSTEM   OF  GYNECOLOGY 

body,  from  the  febrile  disturbance  of  nutrition,  but  the  local  inflamma- 
tory disturbance  affects  its  own  circulation.  Hence  the  most  marked 
cases  of  subinvolution  are  those  associated  with  pelvic  inflammation. 
Again,  when  women  have  many  children  involution  does  not  go  on  so 
fast,  or  take  place  so  perfectly,  as  after  their  earlier  labours. 

Subinvolution  has  been  attributed  to  certain  other  causes  which 
must  therefore  be  mentioned :  —  (a)  "  General  debility  "  :  this  is  so 
vague  a  term  that  it  may  include  almost  anything,  and  its  effects  can 
neither  be  proved  nor  disproved.  (6)  Parturition  late  in  life :  the  effect  of 
multiparity  has  been  mentioned,  and  women  who  have  had  many  children 
are  generally  elderly ;  but  apart  from  multiparity,  there  is  no  evidence 
that  the  completeness  of  involution  at  all  depends  upon  the  patient's  age. 
(c)  Premature  delivery :  there  is  no  evidence  that  after  premature  labours 
free  from  complication  subinvolution  is  more  frequent  than  after  labour  at 
term.  Premature  labour,  hoAvever,  is  often  induced  for  or  by  conditions 
—  such  as  placenta  praevia  or  constitutional  disease  —  which  lead  to  fever, 
or  to  imperfect  contraction  of  the  uterus  ;  for  these  reasons,  and  not  be- 
cause delivery  was  premature,  subinvolution  may  be  more  frequent  after 
premature  deliveries,  (d)  Laceration  of  the  perineum :  Avhen  there  is  a 
large  wound  of  the  genital  passage  the  patient  is  more  likely  to  become 
febrile  than  when  the  mucous  membrane  is  intact ;  for  this  reason  sub- 
involution is  more  frequent  when  the  perineum  is  badly  torn  than  when 
it  is  not  torn ;  but  the  event  is  due  to  the  fever,  not  to  the  rent  in  the 
perineum,  (e)  Lactation:  some  authors  have  stated  that  nursing  favours 
involution,  others  that  it  hinders  it ;  no  facts  have  been  brought  forward 
in  support  of  either  assertion;  nor  do  we  know  the  effect  of  lactation  on 
involution.  (/)  Lacerations  of  the  cervix  uteri :  these  have  no  influence 
on  involution.  They  are  so  high  up  that  in  a  well-managed  confinement 
pathogenetic  microbes  do  not  get  access  to  them,  and  thus  do  not  get  the 
opportunity  of  causing  fever,  {(j)  Plural  pregnancy :  as  the  uterus  is 
here  bigger  than  usual,  involution  may  be  slower ;  but  I  know  of  no  proof 
that  it  is  so.  (/t)  Other  alleged  causes :  phthisis,  diabetes,  Bright's  disease, 
syphilis,  chronic  suppuration,  pneumonia,  bronchitis,  emphysema,  heart 
disease,  rheumatism,  mental  disturbance,  chorea,  eclampsia,  bad  sanita- 
tion, retroversion  of  the  uterus,  have  all  been  said  to  hinder  involution ; 
but  I  have  not  found  a  particle  of  evidence  to  prove  this  effect  of  any 
one  of  them.  They  may  or  they  may  not  cause  subinvolution ;  we  have 
no  knowledge  on  the  subject. 

Effects  of  subinvolution.  — Subinvolution  in  itself  produces  no  disturb- 
ance of  health.  The  uterus  is  often  found  large,  but  otherwise  normal, 
in  women  who  have  had  many  children,  and  are  quite  well,  but  in  whom 
examination  was  made  because  some  disease  was  suspected. 

A  tissue  that  is  in  any  way  degenerated  is  more  vulnerable  under 
adverse  influences  than  one  which  is  h(!althy.  Emphysematous  lungs  are 
more  liable  to  bronchitis  than  healthy  ones.  A  woman  who  has  often 
suffered  from  the  a.'d(;nia  common  in  pregnancy,  is  more  likely  to  get 
her  feet  swollen  from  fatigue  than  one  whose  feet  have  never  been 


INJURIES  IN  PARTURITION  447 

oedematous.  A  uterus  not  well  involuted  is  more  liable  to  disturbances 
of  its  circulation,  and  to  the  morbid  changes  resulting  therefrom,  than  a 
healthy  uterus.  The  diseases  to  which  subinvolution  makes  the  patient 
more  liable  than  she  was  before  are  described  in  other  parts  of  this 
System. 

Subinvolution  of  the  vagina.  —  During  pregnancy  the  vagina  develops 
as  well  as  the  uterus ;  its  vessels  increase  in  number  and  size,  it  becomes 
larger,  and  its  wall  is  thicker  and  softer.  These  changes  obviously  fit  it 
for  dilatation  during  child-birth.  After  delivery  it  undergoes  involution ; 
it  becomes  less  vascular,  its  capacity  less,  its  mucous  membrane  firmer 
and  thinner.  So  far  as  I  know  the  minute  anatomy  of  these  changes  has 
not  yet  been  studied.  In  women  who  have  had  many  children  the  in- 
volution of  the  vagina  is  often  incomplete  ;  the  canal  remains  larger,  its 
mucous  membrane  thicker,  its  rugse  larger.  This  subinvolution  renders 
it  more  liable  to  catarrh,  and  women  who  have  had  children,  especially 
those  in  whom  the  vagina  is  large  and  relaxed,  are,  therefore,  more  sub- 
ject to  leucorrhoea  than  virgins. 

Treatment  of  siih involution.  A.  Preventive.  —  In  the  management 
of  child-birth  subinvolution  is  to  be  prevented  (a)  by  taking  care  that  no 
part  of  the  placenta  or  the  membranes  is  left  behind  in  the  uterus ;  {h)  by 
the  daily  administration  of  ergot  for  three  or  four  weeks  after  delivery. 
This  drug  has  no  effect  upon  normal  involution ;  if,  therefore,  it  is  cer- 
tain that  everything  is  taking  a  normal  course,  the  drug  is  unnecessary. 
But  when  any  adverse  condition  prevents  proper  contraction  of  the 
uterus,  ergot  will  hasten  involution  by  making  the  uterus  contract.' 
(c)  By  not  allowing  the  patient  to  get  about  too  soon,  (d)  I  think, 
though  I  cannot  adduce  evidence  in  support  of  my  opinion,  that  the 
use  of  astringent  antiseptic  douches  during  the  lying-in  period  promotes 
involution  of  the  vagina. 

B.  Curative.  —  When  the  puerperal  state  is  over,  and  involution  slill 
incomplete,  no  treatment  will  make  the  uterus  get  smaller.  One  event, 
and  one  only,  will  alter  the  state  of  the  uterus ;  that  is,  another  preg- 
nancy. If  the  patient  become  pregnant,  the  uterus  in  the  succeeding 
puerperium,  if  no  contrary  cause  again  hinder  involution,  may  fall  ([uite 
to  its  natural  size,  or  even  below  it. 

Superinvolution  of  the  Uterus.  —  What  is  superinvolution  ?  The  word 
means  that  the  uterine  involution  does  not  stop  at  the  restoration  of  the 
uterus  to  its  former  size,  but  goes  beyond  this  point,  and  leads  to  per- 
manent diminution  of  the  size  of  the  organ  and  arrest  of  its  functional 
activity.  The  ill-formed  word  *'  superinvolution  "  was  introduced  by  Sir 
James  Simpson ;  but  the  disease  had  been  previously  described  under  the 

1  In  a  paper  by  Dr.  C.  Owen  Fowler  and  the  author  (Obst.  Ti'ons.,  vol.  xxx.) ,  evidence 
is  published  that  in  a  series  of  unselected  cases  in  which  erjjot  was  jjiveu,  invohilion  was 
less  often  delayed  than  in  a  series  in  which  er^ot  was  not  given.  The  late  Dr.  Hlanc.  ivf 
Lyons,  about  the  same  time  publislied  a  paper  (see  Lancet,  1892  v.  2.  p.  IKiO),  in  which 
lie  compared  two  sets  of  cases,  one  with  and  one  without  ergot,  and  found  that  there  was 
no  difference  in  the  rate  of  involution.  But  Dr.  Blanc  excluded  all  abnormal  cases  from 
his  observations:  his  results  are  therefore  in  harmouj'  with  the  view  stated  in  the  tcxi. 


448  SYSTEM  OF  GYNj^COLOGY 

better  name  by  -n-hicli  it  is  still  known  in  Germany,  namely,  "  puerperal 
atrophy  of  the  nterus."  This  term  at  once  denotes  its  nature  and  its 
pathological  alliance  with  atrophy  of  the  uterus  occurring  in  other 
circumstances. 

Morbid  anatomy.  —  German  writers  speak  of  "excentric"  and  ''con- 
centric "  atrophy.  Excentric  atrophy  means  that  the  cavity  of  the 
iiterus  retains  its  natural  dimensions,  but  that  the  wall  of  the  organ  is 
thinned,  so  that  its  external  measurements  are  smaller.  Concentric 
atrophy  means  that  besides  the  wasting  ot  its  wall,  the  uterine  cavity 
is  diminished  in  length  and  breadth.  It  is  reasonably  believed  that 
excentric  atrophy  is  an  early  stage  of  concentric  atrophy.  It  is  easy  to 
recognize  concentric  atrophy ;  but  in  the  case  of  excentric  atrophy  it  is 
difficult  to  say  what  degree  of  thinning  of  the  uterine  wall  should  be 
regarded  as  pathological,  and  very  difficult  to  be  certain  of  the  existence 
of  slight  thinning.  Hence  statements  about  uterine  atrophy,  based  on 
the  supposition  of  excentric  atrophy,  are  to  receive  only  a  provisional 
acceptation.  It  is  said  by  German  authors  that  some  excentric  atrophy 
takes  place  naturally  during  lactation  ;  and  that  after  weaning  the  uterus 
returns  to  its  normal  thickness.  It  is  difficult  to  be  sure  of  this,  for  we 
have  no  means,  in  the  living  subject,  of  measuring  the  thickness  of  the 
uterine  wall ;  the  fact  of  thinning  rests  only  upon  the  impression  of 
slightly  diminished  size  gained  by  bimanual  examination.  Judging  as 
well  as  I  can  in  this  imperfect  way,  I  am  disposed  to  think  that  the 
German  observers  are  correct.  In  superin volution  this  normal  atrophy 
of  lactation  goes  on  to  a  higher  degree,  and  is  permanent. 

When  atrophy  has  advanced  to  the  degree  denoted  by  the  word 
"  superinvolution,"  the  uterus  is  smaller  in  all  its  dimensions,  and  its 
wall  is  thinner ;  its  mucous  membrane  is  either  absent  or  very  thin; 
its  muscular  tissue  is  thinned,  the  fibres  are  closely  packed,  aiid  among 
its  fibres  thrombosed  and  obliterated  vessels  are  to  be  seen. 

Etiology.  —  Certain  puerperal  diseases  are  followed  by  atrophy  of 
the  uterus.  These  are  (a)  any  puerperal  illness  leading  to  cachexia, 
that  is,  to  wasting  and  anaemia ;  {h)  suppuration  of  the  ovaries  leading 
to  their  destruction;  (c)  pelvic  cellulitis  leading  to  a  fibrous  induration 
which,  constricting  the  vessels,  cuts  off  part  of  the  uterine  blood-supply  ; 
(d)  inflammation  of  such  severity  as  to  lead  to  sloughing  of  the  inner 
])art  of  the  uterine  wall  —  the  so-called  "  endometritis  dissecans." 
These  diseases  are  rare,  and  recovery  from  them  is  rarer  still.  Puer- 
peral atrophy  of  the  uterus  is  also  an  unusual  disease.  Hence  the 
relation  between  these  rare  conditions  is  supported  by  a  very  few  obser- 
vations. We  know  not  what  are  the  morbid  changes  in  the  ovaries,  if 
any,  upon  which  superinvolution  depends. 

There  are  also  diseases  which  may  lead  to  amenorrhnea  and  atrophy 
of  the  uterus,  apart  from  the  puer])eral  state;;  it  seems  a  reasonable 
inference,  therefore,  that  if  they  occurred  in  pregnancy  they  would  lead 
to  atrophy  of  the  uterus  during  the  puerperium  :  but  their  influence  in 
this  way  is  but  a  probability,  not  a  fact  verified  by  observation.     Among 


INJURIES  IN  PARTURITION  449 

them  are  phthisis,  diabetes,  Addison's  disease,  Graves'  disease,  myxce- 
dema,  insanity,  emotional  shock,  paraplegia. 

The  foregoing  are  possible  causes.  The  disease  is  so  rare  that  no 
series  of  cases  large  enough  to  place  the  ordinary  causation  of  super- 
involution  beyond  dispute  has  yet  been  published.  It  is  certain  that 
superinvolutiou  sometimes  occurs  in  women  in  whom  not  one  of  the 
causes  assigned  for  it  (and  enumerated  above)  has  been  present,  and  in 
whom  examination  reveals  no  other  departure  from  the  normal  than  that 
the  uterus  has  undergone  atrophy. 

Symptoms.  —  The  only  invariable  symptom  is  amenorrhoea.  Sterility 
is  probably  a  consequence,  but  as  the  essential  condition  for  fertility  in 
the  female  is  not  the  state  of  the  uterus,  but  the  production  of  healthy 
ova  (as  shown  by  the  occurrsnce  of  pregnancy  in  a  rudimentary  uterine 
cornu),  it  cannot  be  asserted  that  superinvolutiou  directly  or  necessarily 
causes  sterility.  Superinvolutiou  probably,  indeed,  depends  on  ovarian 
atrophy ;  but,  as  I  have  stated  above,  no  morbid  changes  in  the  ovaries 
associated  with  superinvolutiou  have  yet  been  demonstrated. 

As  the  climacteric  is  really  produced  by  superinvolutiou,  the  changes 
and  symptoms  usual  at  the  climacteric  gradually  supervene.  The  breasts 
waste,  and  the  patients  complain  of  the  chills,  flushes,  and  sweats  which 
usually  trouble  women  at  the  menopause.  The  only  other  symptoms 
that  I  have  seen  associated  with  superinvolutiou  are  frequent  headaches 
and  leucorrhoea.  Sir  James  Simpson  says  that  superinvolutiou  is 
associated  with  "constitutional  ill  health,"  "general  debility,"  "depres- 
sion and  impaired  activity  of  mind."  This  is  no  doubt  true,  but  it  is 
difficult  to  disentangle  cause  and  effect,  and  to  be  sure  whether  super- 
involution  is  the  cause  of  ill  health,  or  the  ill  health  the  cause  of  the 
superinvolutiou.  In  my  judgment  the  latter  view  is  the  true  one;  I 
do  not  think  that  any  symptoms  belong  to  superinvolutiou  except 
amenorrhoea,,  sterility,  and  the  usual  climacteric  disturbances. 

Diagnosis  of  superinvolution  of  the  uterus. — The  diagnosis  is  suggested 
by  the  history,  which  is  that  of  amenorrhoea  dating  from  the  birth  of  a 
child  and  continuing,  although  the  patient  has  long  ceased  to  suckle.  It 
is  made  certain  by  finding  out  by  physical  examination  the  smallness  of 
the  uterus.  This  is  done  in  three  ways:  —  (a)  By  passing  the  sound. 
In  this  way  the  length  of  the  uterine  cavity  can  be  accurately  measured. 
A  fallacy  attends  it,  namely,  that  the  sound  may  not  have  passed  the 
whole  length  of  the  canal :  therefore  it  needs  to  be  supplemented  by 
methods  of  determining  the  size  as  well  as  the  length  of  the  uterus.  Of 
these  the  best  is  (&)  bimanual  examination,  which  means  grasping  the 
xiterus  between  a  finger  in  the  vagina  and  a  hand  on  the  abdomen. 
Thus  its  size  can  be  well  estimated.  If  this  cannot  be  done  —  either 
because  from  nervousness  the  patient  keeps  the  abdominal  walls  very 
hard,  or  because  she  is  very  fat — then  use  method  (c).  Seize  the  cervix 
with  a  hook  or  volsella  (the  volsella  gives  the  securer  hold,  but  hurts  the 
patient  more),  and  pull  it  down  towards  the  vulva.  Then  insert  a  finger 
into  the  rectum,  and  you  will  feel  the  whole  length  and  breadth  of  the 

2g 


450  SYSTEM  OF  GYNECOLOGY 

posterior  surface  of  the  uterus.  The  smalhiess  of  the  uterus  thus  ascer- 
tained establishes  the  diagnosis  of  puerperal  atrophy. 

Treatm-ent  of  superinvolntion.  —  The  only  method  of  treatment  which 
is  unquestionably  beneficial  is  the  cure,  if  possible,  of  an}^  condition  of 
ill  health  Avhich  may  be  the  cause  of  the  uterine  atrophy.  The  modes 
of  treating  the  different  causes  of  anaemia  and  wasting  are  described  in 
the  medical  sections  of  this  system. 

If  the  patient  be  florid,  and  the  time  at  which  menstruation  should 
occur  is  marked  by  uncomfortable  sensations,  these  symptoms  may  be 
relieved,  and  the  uterus  stimulated  by  the  application  of  leeches  to  the 
cervix  uteri.     Cases  of  this  kind  are  rare. 

Electricity  has  been  recommended.  The  only  kind  of  electricity 
likely  to  be  effective  is  the  passage  of  a  current  through  the  organ 
between  an  electrode  applied  to  the  uterus,  and  one  on  the  abdominal 
wall ;  I  know  of  no  evidence,  however,  that  such  treatment  has  proved 
useful. 

Stem  pessaries,  whether  of  glass,  metal,  or  vulcanite,  have  been  used. 
Sir  James  Simpson  recommended  a  "  galvanic  stem,"  that  is,  an  intra- 
uterine pessary  made  half  of  zinc  and  half  of  copper,  the  two  halves 
lying  side  by  side.  When  this  is  put  into  the  uterus,  the  secretions  of  the 
part  set  up  galvanic  action  between  the  zinc  and  the  copper,  and  chloride 
of  zinc  is  formed,  which,  being  a  caustic,  inflames  the  mucous  membrane 
with  which  it  comes  in  contact.  This  is  an  injurious  action.  I  know  of 
no  evidence  that  the  galvanic  stem  does  any  good.  But  any  intra-uterine 
stem,  however  unirritating  the  material,  may  produce  peritonitis ;  and 
I  know  of  no  evidence  that  such  stems  will  make  a  uterus  which  has 
undergone  superin volution  again  develop  itself.  If  intra-uterine  stems 
of  any  kind  are  to  be  employed  it  should  only  be  after  explanation  to 
the  patient  that  the  instrument  is  not  likely  to  do  good,  and  involves 
some  risk  to  life.  If  the  patient  be  rightly  informed  of  the  small  pros- 
pect of  benefit  from  local  treatment,  the  dangers  involved  in  it,  and  the 
unimportance  of  the  effect  of  superinvolution  upon  health  and  duration 
of  life,  she  will  generally  prefer  to  let  it  alone. 

It  is  to  my  mind  very  doubtful  whether  any  treatment  will  make  a 
uterus,  which  has  fallen  into  atrophy,  again  develop  itself.  In  most  cases 
in  which  the  uterus  is  small  because  it  never  has  developed  treatment  is 
a  failure ;  and  the  prospect  when  the  uterus  has  normally  developed,  has 
been  functionally  active,  and  then  has  wasted  prematurely,  is  far  less 
hopeful. 


G.  Eknest  Herman. 


REFERENCES 


1.  Bauury.  Armali'S  de  Gijnecolof/ie,'Tu\U(it  iH'.)i. — 2.  Bkoers.  Virchoio's  Archiv, 
Bd.  cxli.  July  18'J.j.  —  .'i.  Duncan,  Matthews.  Obstet.  Trans,  vol.  xxxi.  —  4.  Hklmk, 
T.  A.  Trans.  Royal  Socifity  Kd.  vol.  xxxv.  Part  11,  No.  8. — 5.  Herman,  G.  Ehnkst. 
Obstet.  Trans,  vols.  xxix.  xxxi.  —  (J.  Kklly.  American  Syslcm  of  (h/ri,"mlo(/y  and 
Ohsletrics,  art.  "  Injuri(j.s  and  Lacerations  of  tlio  Perineum  and  Pelvic.  Floor."— 7. 
KLEI3.S.      Handbuch  der  palhologisi;lie   Anatomie,  p.  870. —8.    Kloij.      Pa(holo:j:(ul 


EXTRA-UTERINE    GESTATION  451 

Anatomy  of  the  Female  Sexual  Organs,  translated  by  Kammerer  and  Dawson,  18G8, 
p.  127.  —  y.  Neugebauer.  Arch,  fiir  Gyn.  Bd.  xxxiv.  — 10.  Ramsboth^vm,  F.  H. 
Obstet.  Med.  and  Surgery.  —  11.  Ries.  Zeil.fiir  Geb.  and  Gya.  Bd.  xxiv.  — 12.  Schatz. 
Arch,  fiir  Gyn.  Bd.  xxii.  1884,  S.  298.  —  lo.  Simpson,  Sir  James.  Works,  vol.  iii. 
p.  C02.  — 14.  Skene.  New  York  Med.  Journal,  March  14,  1.S85.  — 15.  Williams,  Sir 
J.  Obstet.  Trans,  vol.  xx. — 10.  Williams,  Sir  J.  Brit.  Med.  Jour,  1882,  vol.  ii. 
See  also,  on  Rupture  of  Perineum,  Duncan,  Matthews.  Papers  on  the  Female 
Perineum,  and  on  JNIethods  Proijosed  to'  Prevent  it,  JNIerkerttschiantz,  Arch,  fiir 
Gyn.  Bd.  xxvi.,  and  Leishman,  Glasgow  Medical  Journal,  18G0.  On  Lacerations  of 
Vagina,  Freund,  Gyniikolog.  Klinlk.  On  Puerperal  Atrophy  of  Uterus,  Thorn, 
Zeit.  fiir  Geb.  und  Gyn.  Bd.  xvi. ;  Frommel,  Zeit.  fiir  Geb.  und  Gyn.  Bd.  vii. ;  Ries, 
Zeit.  fiir  Geb.  und  Gyn.  Bd.  xxvii.;  Gottschalk,  Volkmann's  Vortrage,  N.  F.  4Si. 

G.  E.  H. 


EXTEA-UTERINE  GESTATION 

Normal  pregnancy,  or  the  state  of  "  being  with  young,"  is  the  outcome 
of  two  factors  —  i.  Imjjregnation.  ii.  The  retention  of  an  oosperm  in 
the  cavity  of  the  uterus. 

In  order  to  reach  the  uterine  cavity  the  ovum  must  traverse  the 
Fallopian  tube.  When  an  oosperm  (fertilised  ovum)  is  retained  in  the 
tube  it  continues  to  develop,  and  gives  rise  to  the  condition  known  as 
tubal  pregnancy. 

The  causes  of  tubal  pregnancy  are  unknown ;  and  our  ignorance 
will  continue  until  we  have  some  trustworthy  information  concerning 
the  situation  in  the  genital  passages  where  ovum  and  spermatozoon 
normally  meet.  It  is  probable  that  fertilisation  normally  happens  in 
the  uterus,  and  that  when  it  occurs  in  the  tube  it  is  accidental,  and 
tubal  gestation  the  consequence. 

Obstruction  to  the  transit  of  ova  will  not  explain  matters,  for  an 
oosperm  is  more  often  retained  in  the  Avide  ampullary  section  of  the  tube 
than  in  its  uterine  segment.  My  own  observations  teach  me  that  tubal 
pregnancy  is  the  result  of  active  rather  than  of  obstructive  causes.  The 
union  of  a  spermatozoon  with  the  nucleus  of  an  ovum  not  merely  initiates, 
in  the  previously  passive  cell,  most  marvellous  and  rapid  changes  ending, 
under  favourable  conditions,  in  the  production  of  a  new  individual ;  but 
in  some  unknown  way  exerts  also  an  extraordinary  influence  on  the  re- 
productive organs.  Hence  it  is  probable  that  when  an  ovum  is  fertil- 
ised, the  resulting  oosperm  engrafts  itself  at  once  on  the  adjacent 
mucous  membrane,  whether  tidial  or  uterine. 

Tubal  pregnancy  may  happen  as  a  first  pregnancy  in  women  who 
have  been  married  eight,  ten,  or  even  twenty  years.  A  woman,  thirty- 
seven  years  of  age,  from  whom  I  removed  a  gravid  tube  five  weeks  after 
primary  rupture,  had  been  twice  married,  and  her  matrimonial  life  had 
extended  over  seventeen  years ;  yet  her  first  pregnancy  was  tubal.   Tubal 


452 


SYSTEM   OF  GYNAECOLOGY 


pregnancy  may  follow  normal  gestation,  or  an  abortion,  within  a  few 
months;  or  it  may  occur  as  a  first  pregnancy  in  a  woman  of  twenty  or 
forty  years;  A  Fallopian  tube  may  become  gravid  in  the  newly  married, 
or  in  the  mother  of  a  large  family.  Both  tubes  may,  in  very  exceptional 
instances,  be  gravid  concurrently  ;  or  one  tube  may  become  pregnant  years 
after  its  fellow.  In  very  rare  cases  two  oosperms  are  retained  in  the  same 
Fallopian  tube — ticintubaljjregnancy  ;  or  !iga,in,tHbaI  may  comj^licate  uterine 
pregnancy.  An  analysis  of  a  large  number  of  cases  establishes  the  fact 
that  the  occurrence  of  tubal  pregnancy  is  often  preceded  by  a  long  in- 
terval of  sterility.  As  this  last  statement  is  often  used  in  an  uncertain 
manner,  it  will  be  useful  to  attach  some  definite  meaning  to  it. 

Matthews  Duncan,  from  a  careful  consideration  of  3722  cases  of 
delivery,  came  to  the  conclusion,  ''  that  there  is  no  good  presumption  of 
sterility  until  the  fourth  year  of  married  life  has  been  entered  upon," 
and  the  accompanying  table  shows  the  intervals  between  marriage  and 
the  birth  of  the  first  child  in  his  collected  cases  :  — 


Less  than  \ 
one  year  J 

608 

9 

years  5 

10 

,,   1 

1 

2390 

11 

M   3 

2   ,, 

437 

12 

,,   4 

3   „ 

133 

13 

n   2 

4   „ 

61 

14 

n   0 

5   „ 

32 

15 

„   1 

6   ,, 

27 

16 

n   0 

7   „ 

12 

17 

n    0 

8   „ 

5 

18 

,,    1 

Taking  these  facts  as  a  basis  it  will  be  convenient,  in  considering 
tubal  jjregnancy,  to  regard  an  unfruitful  interval  of  four  years  after 
cohabitation  as  a  "  period  of  sterility  " ;  eight  years  would  be  a  long, 
and  sixteen  years  a  very  long  period  of  sterility. 

In  order  to  obtain  further  evidence  in  relation  to  this  matter,  I 
collected  100  cases  of  tvibal  pregnancy  reported  in  American,  British, 
French,  and  German  literature,  in  order  to  determine  as  nearly  as  possi- 
ble the  most  common  period  of  life  for  this  accident.  The  cases  were 
distributed  thus :  — 

Between  the  ages  of  20  and  25,     10  cases. 
25  and  40,     86      „ 
,,  ,,       40  and  45,      4      ,, 

100     „ 

The  number  of  cases  within  each  lustrum,  25-30,  30-35,  35-40, 
were  almost  equally  distributed:  I  have  further  tested  the  conclusion 
by  reference  to  my  own  cases,  and  those  I  have  witnessed  in  the  prac- 
tice of  my  colleagues,  and  the  results  are  veiy  constant. 

In  regard  to  uterine  gestation,  Matthews  J^uncan  points  out  that  the 
interval  25-35  may  be  regarded  as  the  great  child-bearing  period  of  life, 


EXTRA-UTERINE    GESTATION  453 

and  that  the  average  duration  of  the  child-bearing  period  is  twelve  years. 
I  may  add  that  in  some  cases  in  the  lustrum  35—40  the  foetus  had  been 
sequestered  in  the  mesometrium  (broad  ligament)  for  several  years,  so  that 
the  period  of  functional  activity  of  the  uterus  represents  also  the  period 
of  liability  of  the  tubes  to  become  gravid. 

Clinical  experience  has  taught  me  that  these  facts  in  regard  to  age, 
child-birth,  and  a  preceding  "  period  of  sterility,"  are  points  to  be  con- 
sidered in  dealing  Avith  suspected  cases  of  tubal  pregnancy. 

The  occurrence  of  pregnancy  in  the  Fallopian  tubes  after  a  long  period 
of  sterility  in  women  who  have  borne  children,  has  led  some  writers  to 
believe  that  these  patients  had  suffered  from  desquamative  salpingitis, 
and  that  the  destruction  of  the  tubal  epithelium  had  hindered  the  ovum 
in  its  passage  to  the  uterus. 

I  have  devoted  much  labour  to  the  investigation  of  the  minute  changes 
in  the  mucous  membrane  of  gravid  tubes.  In  some  specimens  there  is 
evidence  of  old  inflammation ;  but  it  must  be  pointed  out  that  salpingitis, 
so  severe  as  to  produce  destruction  of  the  tubal  epithelium,  causes  profound 
changes  in  the  tubes,  and  leads  to  stricture  and  complete  occlusion  of  their 
abdominal  ostia ;  when  the  tubes  are  denuded  of  their  epithelium  it  is 
exceedingly  rare  to  find  the  abdominal  ostia  patent.  It  is,  however, 
well  to  bear  in  mind  that  salpingitis,  even  of  a  mild  type,  may  so  affect 
the  tubal  mucous  membrane  as  to  retard  or  altogether  hinder  the  transit 
of  ova;  and  an  examination  of  pregnant  tubes  shows  that  salpingitis  of  a 
mild  type,  and  without  even  partial  destruction  of  the  epithelium,  will 
lead  to  the  detention  of  ova  and  expose  them  to  spermatozoa,  which  may 
wander  into  the  tubes.  On  the  other  hand,  in  many  specimens  of  very 
early  tubal  pregnancy  I  have  failed,  even  after  the  most  careful  micro- 
scopic examination,  to  find  any  evidence  of  old  salpingitis  or  loss  of 
epithelium. 

It  is  probable  that  in  a  small  proportion  of  cases  chronic  salpingitis 
of  a  mild  type  may  account  for  the  sterility  and  the  subsequent  tubal 
pregnancy ;  but  it  fails  to  account  for  a  very  large  number  of  instances. 
Indeed  the  evidence  now  indicates  that  a  healthy  Fallopian  tube  is 
more  liable  to  become  gravid  than  one  which  has  been  inflamed. 
Chronic  salpingitis  becomes  even  less  satisfactory  as  an  explanation  of 
tubal  pregnancy,  Avhen  we  reflect  that,  in  some  of  the  specimens,  the 
inflammatory  changes  are  the  consequence  rather  than  the  cause  of 
tubal  pregnancy.  Although  changes  of  this  character,  or  mechanical 
conditions  induced  by  the  presence  of  ovarian,  parovarian,  or  uterine 
tumours,  may  explain  a  fcAv  cases,  the  causes  of  tubal  pregnancy  in 
most  cases  remain  undetected. 

Our  knowledge  of  the  events  consequent  on  the  retention  of  an 
oosperm  in  the  tube  is  fairly  complete ;  and,  as  they  vary  according  to 
its  position,  gestation  in  the  ampulla  and  the  isthmus  is  called  tubal,  and 
in  the  portion  which  traverses  the  uterine  wall  tuho-uterine  pregnancy. 
This  latter  variety  will  require  separate  consideration. 

The  stages  of  tubal  pregnancy  Avill  be  discussed  in  sections  thus :  — 


454  SYSTEM  OF  GYNECOLOGY 

i.  Changes  in  the  tube.  ii.  The  tubal  mole.  iii.  Tubal  abortion,  iv. 
Tubal"  rupture,     v.  The  decidua  and  the  placenta. 

i.  Tlie  Chcaiges  in  the  Tube.  — During  the  first  month  or  six  Aveeks  that 
portion  of  the  tube  in  'n'hich  the  oosperm  is  lodged  becomes  very  vascular 
and  turgid.  Occasionally  the  walls  of  the  tube,  at  the  site  ^vhere  the 
villi  are  implanted  on  the  mucous  membrane,  stretch  and  grow  thin  from 
the  beginning  of  the  gestation.  The  rapidity  of  the  thinning  varies  in 
different  tubes;  this  is  due  to  the  fact  that  under  normal  conditions 
the  Fallopian  tubes  vary  not  only  in  length  but  in  thickness.  In  some 
individuals  they  scarcely  exceed  in  thickness  the  vasa  deferentia  of  the 
male,  and  resemble  rather  the  narrow  tubes  of  the  mare  or  cow.  As 
the  tube  expands  from  the  growth  of  the  foetus  and  its  membranes,  the 
mucous  membrane  is  stretched  and  its  folds  effaced.  Occasionally  a  few 
of  the  plicae  will  project  Avithin  the  tube  as  long  straggling  processes. 

"Whilst  these  changes  are  in  progress  curious  alterations  are  taking 
place  at  the  abdominal  ostium,  which,  in  many  cases,  gradually  bring 

about  its  occlusion  ;  an  event  usually  com- 
pleted by  the  eighth  week.  During  the 
tirst  four  weeks  the  congestion  of  the  parts 
causes  turgescence  of  the  fimbrite,  as  well 
as  of  the  muscular  and  serous  tissues  ad- 
jacent to  them.  AVhen  the  parts  are  thus 
swollen  the  margin  of  peritoneum  adjacent 
to  the  ostium  is  very  conspicuous,  and 
forms  an  irregular  ring  around  the  fimbriae. 
In  another  fourteen  days  this  ring  projects 
beyond  the  fimbriae;  lastly,  it  contracts  and 
hermetically  closes  the  ostium. 
Fig.  129. -Dilated  abdominal  ostium:  Careful    observations  of   gravidtubcs 

from  a  pravid  mole-containing  tube.     SCrve  tO  sllOW  that  OCclusioU  of  the  abdouii- 

^  "^'  "'^^'^  nal  ostium  is  by  no  means  a  constant  sequel 

of  tubal  gestation ;  indeed,  in  some  instances,  as  the  tube  is  distended  by 
the  growing  embryo,  the  ostium  dilates :  I  have  examined  specimens  in 
which  the  abdominal  ostium  appeared  as  a  circular  opening  4  cm.  in 
diameter  (Fig.  129).  It  would  appear  that,  when  the  oosperm  is  retained 
near  the  abdominal  ostium,  this  aperture  is  more  likely  to  become 
occluded  than  when  it  is  lodged  near  the  middle  of  the  tube.  When 
the  oosperm  is  detained  in  the  inner  third  of  the  tube  the  ostium  is 
unaffected  (Fig.  130). 

The  condition  of  the  mouth  of  the  tube  iu  some  measure  influences 
the  subsequent  course  of  tlie  pregnancy,  inasniuch  as  a  widely  expanded 
ostium  disposes  to  tuljal  abortion ;  but  a  gravid  tube  witli  a  patent  ab- 
dominal ostium  is  also  lialjle  to  rupture.  A  gravid  tube  with  an  occluded 
ostium  almost  invariably  jjursts. 

Our  knowledge  of  the  condition  of  the  uterine  segment  of  the  tube 
in  cases  of  tubal  pregnancy  is  less  X'^ecise  than  that  of  the  abdominal 
ostium,  because  mere  examination  with  the  naked  eye,  or  such  rough 


EXTRA-  UTERINE    GESTA  TION 


455 


methods  as  the  introduction  of  a  probe,  or  a  bristle,  are  not  satisfactory 
tests.  The  best  means  of  investigation  consist  in  the  microscopical 
examination  of  thin  sections  of  the  uterine  segment  of  the  tube.  This 
has  been  carried  out  in  a  few  instances,  and  the  lumen  of  the  tube  found 
to  be  uninterrupted. 

The  condition  of  the  uterine  segment  of  the  tube  is  of  some  importance 
in  connection  with  the  clinical  features  of  tubal  gestation.  It  was  assumed, 
by  some  of  the  older  writers  on  extra-uterine  gestation,  that  obstruction 
in  this  part  of  the  tube  would  help  to  explain  retention  of  the  ovum  in 
the  tube.  This  is  of  course  untenable,  because  it  would  likewise  prevent 
the  entrance  of  spermatozoa  into  the  tube.     In  many  cases  of  tubal 


Gestation  sac 


Parovarium 


Ostium 


Corpus  luteum       Punctum 


Fig.  130. — Gravid  tube  ;  the  gestation  sac  occupied  the  uterine  segment  of  the  tube.     The  mole  was 
equal  to  a  green  pea  in  size.     The  abdominal  ostium  was  patent,     {i^at.  size.) 


gestation  the  patient  complains  of  irregular  discharges  of  blood  from  the 
vagina ;  this  seems  to  be  observed  more  especially  in  cases  of  tubal 
abortion.  It  is  probable  that  some  of  this  blood  is  effused  into  the  tube 
and  trickles  through  the  uterine  orifice  into  the  cavity  of  the  uterus. 

Tubal  Moles.  — The  changes  which  occur  in  the  oosperm  subsequent  to 
impregnation  are  identical,  whether  it  be  retained  in  the  tube  or  the 
uterine  cavity.  In  either  situation  it  is  liable  to  a  curious  change  whereby 
it  is  converted  into  what  is  known  as  a  mole. 

Practitioners  are  familiar  with  uterine  moles  :  they  are  so  common 
that  most  pathological  museums  contain  several  specimens,  and  few 
matrons  terminate  the  reproductive  period  of  life  without  having  pro- 
duced one  or  more  examples  of  the  fleshy  mole.  The  clinical  name 
for  the  event  is  "abortion."     When  a  mole  is  examined  soon  after  its 


456 


SYSTEM  OF  GYNAECOLOGY 


discharge  it  resembles  a  firm  blood-clot  in  colour  and  consistence.  On 
dividing  it,  a  cavity  is  found  containing  tluid,  "wliich  is  sometimes  straw- 
coloured,  sometimes  stained  red  from  admixture  with  blood.  The  walls 
of  this  cavity  are  smooth  and  lined  with  amnion,  and  often  a  misshapen 

foetus  is  contained  with- 


Chorion 


Clot 


Embrv' 


Fig.  131.  — Tubal  mole  in  section.     {Nat.  size.) 


in,  or  the  stump  of  an  um- 
bilical cord ;  f  requentl}^, 
however,  there  is  no  trace 
of  an  embryo. 

In  1889  I  was  able  to 
demonstrate  that  moles 
occur  in  connection  with 
tubal  pregnancy ;  and 
since  that  date  such  a 
large  number  of  exam- 
ples have  been  described 
that  the  tubal  mole  has 
become  a  familiar  object. 

The  characters  of  tu- 


bal moles  may  be  summarised  thus :  — 

Tubal  moles  vary  greatly  in  size ;  some  have  a  diameter  of  1  cm., 
others  of  5  or  even  8  cm.  Small  moles  are  globular,  but  after  attaining 
a  diameter  of  3  cm.  they  assume  an  ovoid  shape. 

The  amniotic  cavity  usually  occupies  an  excentric  position  (Fig.  131). 
Occasionally  an  embryo  is  present ;  often  it  is  misshapen  and  ill-developed. 

In  a  great  many  specimens,  owing  to  the  excentric  position  of  the 
amniotic  cavity,  its  walls  are  ruptured  and  the  embryo  is  lost. 

The  outer  investing  membrane  —  the  chorion  —  is  usually  shaggy  with 
villi,  which  become  more  obvious  if  the  mole  be  exposed  to  a  gentle 
stream  of  water. 

In  some  specimens  the  amniotic  cavity  is  effaced ;  if  such  moles  be 
sectioned  and  examined  microscopically,  the  chorionic  villi  will  be  found 
cut  transversely  or  obliquely. 

Recent  moles  resemble  a  piece  of  blood  coagulum  and  are  dark  red. 
When  they  have  been  free  in  the  peritoneal  cavity  (coelom)  or  lodged 
between  the  layers  of  the  mesometrium  (broad  ligament)  for  days  or 
weeks  they  are  sometimes  yellow  externally,  and  often  firm  and  liard. 

The  majority  of  tubal  moles  are  easily  recognised ;  but  a  doubt  may 
arise  when  the  amniotic  cavity  is  obliterated.  In  a  doubtful  case  of  this 
kind  the  presence  of  chorionic  villi  determines  its  nature.  The  villi 
usually  appear  as  clusters  of  circular  bodies ;  ten  or  more  may,  in  fortunate 
sections,  be  counted  together  :  more  frequently  they  occur  in  groups  of 
three  or  four,  and  often  a  wide  section  of  clot  may  be  examined  without 
finding  more  than  two  or  three.  Under  a  low  ])0wer  they  present  an 
externallayer  of  epithelium,  the  central  space  being  occupied  by  irregular- 
shaped  cells  (Fig.  132).  When  examined  under  high  powers  a  limiting 
layer  of  cubical  epithelium,  forming  a  perfectly  regular  row,  is  often  to  be 


EXTRA-UTERINE    GESTATION 


457 


seen.  Sometimes  the  interior  of  a  villus  resembles  the  stratum  inter- 
medium of  an  enamel  organ.  In  larger  villi  there  is  often  a  double  row 
of  epithelium. 

The  structure  and  mode  of  formation  of  these  moles  are  of  great 
interest.  In  the  early  stages  of  development  the  relations  of  the  mem- 
branes are  somewhat  different  to  those  which  obtain  at  a  later  period,  and 
it  is  a  significant  fact  that  moles  only  arise  in  the  first  few  weeks  following 


CHonroNic 

VILLI 


Fig.  132.  —  Microscopical  characters  of  chorionic  villi  in  section,  in  blood-clot. 


fertilisation.  Soon  after  the  chorion  is  shagg}^  with  villi  the  embrj'o  will 
be  found  in  the  amnion ;  between  the  amnion  and  the  chorion  a  space  ex- 
ists (which  maybe  called  the  subchorionic  chamber)  filled  with  albuminous 
fluid  (Fig.  133).  As  the  embryo  increases  in  size  the  amnion  gradually 
encroaches  on  this  space  and  eventually  obliterates  it;  but  for  a  time  a 
potential  space  exists  between  the  two  membranes  (Fig.  134)  exactly 
resembling  that  between  the  visceral  and  parietal  pleura. 

The  most  cursory  examination  of  a  typical  tubal  mole  will  convince 
the  observer  that  the  blood  is  limited  externall}'  by  the  chorion  and 
internally  by  the  amnion  (Fig.  131).    It  is  obvious  that  this  blood  occupies 


45S 


SYSTEM  OF  GVjV^COLOGV 


the  subchorionic  chamber.  This  at  once  explains  the  elliptical  shape  of 
large  tiibal  moles. 

We  have  nov^  to  determine  the  source  of  the  blood.  Many  observers 
have  hitherto  been  content  to  believe  that  a  mole  is  formed  by  an  irruption 
of  maternal  blood  into  the  embryonic  membranes.  In  the  face  of  the 
observed  facts  mentioned  above  this  loose  opinion  falls  to  the  ground. 
The  blood  is  furnished  by  the  circulation  of  the  embryo.  This  view  is 
further  supported  by  the  character  of  the  blood  :  the  blood  of  the  embryo 
differs  from  that  of  the  adult  by  the  fact  that  the  red  corpuscles  are 
nucleated;  now  actual  observations  on  blood  from  fresh  tulial  moles  show 
that  the  red  corpuscles  are  nucleated. 

It  is  clear  that  a  tubal  mole  is  due  to  blood  extravasated  from  the  cir- 
cxdation  of  the  embryo  into  the  subchorionic  chamber. 


Fio.  133. — Diagram  to  show  the  early  relations 
of  the  amnion  and  chorion  and  the  sub- 
chorionic chamber. 


Fig.  134. — An  early  tubal  embryo, 
showing  the  polar  disposition  of 
the  villi,  etc.     {Nat.  size.) 


It  must  be  distinctly  understood  that  these  observations  only  apply 
to  blood  within  the  chorion.  It  does  not  follow  that  the  blood  found 
within  the  subchorionic  chamber  is  the  result  of  a  single  hemorrhage  ; 
careful  examination  of  tubal  moles  demonstrates  that  the  blood  is  often 
disposed  in  laininai  like  that  found  in  a  sacculated  aneurysm.  This  is 
sufHcient  to  prove  that  in  some  instances,  at  least,  the  formation  of  a 
tubal  mole  is  a  gradual  process. 

Jn  many  cases  tuljal  moles  are  found  immersed  in  blood  extravasated 
from  the  maternal  vessels.  Occasionally  mole-containing  tubes  come 
to  hand  in  whicli  no  blood  is  effused  between  the  chorion  and  the  tube. 
In  such  cases  evidence  that  the  blood  comes  from  some  source  within 
the  choi'ion  is  irrefragable. 

Tubal  Abortion.  —  It  has  been  pointed  out  already  that  the  presence 
of  an  oosperm  in  the  outer  third  of  a  Fallopian  tube  usually  leads  to 
occlusion  of  the  abdominal  ostium :  this  event  is  commonly  comx>lete  by 


EXTRA-UTERINE    GESTATION  459 

the  end  of  the  sixth  week  ;  sometimes  it  is  delayed  to  the  eiglith  week  ; 
it  is  therefore  a  comparatively  slow  process. 

So  long  as  this  orihce  remains  open  the  oosperm  is  in  constant  jeopardy 
of  extrusion  through  it  into  the  peritoneal  cavity  (coelom),  especially  when 
it  lies  in  the  ampulla  of  the  tube ;  the  nearer  it  is  situated  to  the  ostium 
the  greater  the  chance  of  this  extrusion.  To  this  accident  the  term 
''tubal  abortion"  is  applied,  for  it  is  exactly  parallel  to  those  early 
abortions  occurring  in  uterine  gestation  before  the  end  of  the  second 
month  ;  and  it  further  resembles  them  in  the  fact  that  the  oosperm  is 
nearly  always  converted  into  a  mole. 

The  term  tubal  abortion  is  apj^licable  to  cases  in  which  haemorrhage 
takes  place  from  a  gravid  tube,  the  blood  entering  the  coelom  through 
an  unclosed  ostium. 

Many  of  these  cases  resemble  early  uterine  abortions  in  which  a  mole 
is  expelled,  accompanied  by  a  free  discharge  of  blood  from  the  uterus. 
In  tubal  abortion  the  same  thing  happens.  The  mole  is  discharged  with 
a  copious  haemorrhage  into  the  peritoneal  cavity  through  the  ostium  ;  the 
patient  presents  the  usual  signs  of  internal  bleeding,  and  rapid  death  may 
occur  from  the  consequent  anaemia,  or  from  shock.  In  such  instances 
the  mole,  being  very  small,  often  escapes  recognition  when  the  clot  is 
examined,  whether  after  an  operation  or  after  death.  Tubal  abortion  can 
only  occur  during  the  first  two  months  ;  for  when  the  ostium  is  occluded 
the  blood  cannot  escape  without  rupture  of  the  sac.  The  quantity  of 
blood  which  flows  from  the  tube  into  the  peritoneal  cavity  sometimes 
amounts  to  two,  three,  or  even  four  litres.  Tubal  abortion  is  a  subject 
of  much  interest,  inasmuch  as  it  furnishes  many  of  the  cases  of  pelvic 
haematocele  which  are  ascribed  to  metrorrhagia,  reflux  of  menstrual  blood 
from  the  uterus,  or  haemorrhage  from  the  mucous  membrane  of  the  Fallo- 
pian tube.  The  reason  for  associating  the  haemorrhage  with  metrorrhagia 
and  menstruation  is  due  to  the  fact  that,  whilst  the  embryo  is  growing  in 
the  tube  a  decidua  is  forming  in  the  uterus.  "When  tubal  abortion  occurs 
haemorrhage  takes  place  from  the  uterus,  consequent  on  the  separation 
and  expulsion  of  the  decidua.  Should  this  accident  happen  near  the  time 
the  patient  expects  to  menstruate,  the  case  would  be  regarded  as  reflux 
of  menstrual  fluid  into  the  peritoneum.  In  some  cases  the  blood  dis- 
charged from  the  uterus  is  derived  from  the  gravid  tube ;  this  especially 
happens  in  cases  of  protracted  tubal  abortion.  If  it  do  not  coincide  with 
a  menstrual  period  it  is  then  usually  considered  to  be  of  uterine  origin. 
It  will  therefore  be  Avell,  in  searching  blood  removed  in  abdominal  opera- 
tions, to  examine  carefully  any  apparently  organised  ovoid  clot,  in  order 
to  ascertain  whether  it  contain  an  amniotic  cavity  with  or  without  an 
embryo,  and  also  to  ascertain  the  existence  or  otherwise  of  chorionic 
villi. 

It  is  necessary  to  bear  in  mind  that  in  early  uterine  abortion  the  mole 
often  fails  to  become  completely  detached  from  the  uterine  wall ;  bleed- 
ing recurs  so  long  as  the  mole  is  retained.  In  tubal  pregnancy  the  same 
thing  happens  ;  the  mole,  so  long  as  it  is  not  ejected  from  the  tube,  gives 


460 


SyST£J/   OF  GYX^COLOGY 


Fig.  135.  —  A  ^avid  tube  with  piatent  ostium  ;  the 
mole  is  shown  in  section.  From  a  case  of  in- 
complete tubal  abortion.     (A'rti.  size.) 


rise  to  recurrent  hcemorrhage  (Fig.  135).   This  may  be  described  as  incom- 
2)lete  tubal  abortion,  and  is  more  common  than  the  complete  form. 

Doubts  have  been  expressed  in  regard  to  tlie  occurrence  of  complete 
tubal  abortion.  In  1892  I  reported  the  details  of  such  a  case  to  the 
Medical  Society  of  London.  At  the  operation  I  found  the  mole  lying 
among  the  fimbriae  of  the  tube.  There  was  a  small  rent  in  the  tube  wall. 
The  tube,  ovary,  and  mole  are  shown  of  natural  size  in  Fig.  136. 

A  few  writers  are  disposed  to  quibble  over  the  term  tubal  abortion. 

There  can  be  little  doubt  that  it 
will  be  possible  in  the  future  to  dis- 
tinguish clinically  between  rupture 
of  a  gravid  tube  and  incomplete 
tubal  abortion ;  the  latter  condition 
certainly  gives  rise  to  repeated 
bleeding.  Besides  this,  the  full  rec- 
ognition of  the  fact  that  a  mole 
may  be  discharged  through  an  un- 
closed ostium  into  the  peritoneal 
cavity  has  helped  to  complete  the 
chain  of  evidence  that  pelvic  haema- 
toceles  have  their  source  in  hasmor- 
rhages  from  gravid  Fallopian  tubes. 

In  tubal  abortion  the  great  danger  lies  in  the  fact  that  the  bleeding 
is  apt  to  be  recurrent  so  long  as  the  mole  is  retained  in  the  tube.  Noble 
has  recorded  briefly  the  details  of  a  case  of  tubal  abortion  in  which  the 
blood-clots  found  in  the  pelvis  were  "  coiled  up  much  as  though  they 
had  been  ground  through  a  sausage  machine  " ;  the  blood  clotted  in  the 
tube,  and  the  clot  was  then  forced  out  as  a  sausage-shaped  mass  by  the 
continuance  of  the  bleeding. 

It  is  a  noteworthy  feature  in  many  instances  of  incomplete  tubal 
abortion  that  the  mole  very  firmly  retains  it  attachment  to  the  tube  wall 
(Fig.  135j ;  the  area  of  fixation  corresponding  to  the  placental  site.  In 
my  early  investigations  into  the  nature  of  tubal  moles  I  found  that  villi 
occurred  abundantly  in  sections  taken  from  one  part,  and  yet  were  absent 
in  those  taken  from  other  parts  of  the  same  mole.  Since  I  detected  the 
striking  polar  congregation  of  villi  displayed  in  Fig.  134, 1  have  always 
taken  my  sections  from  the  adherent  pole,  and  have  so  far  never  failed 
to  find  the  villi  in  great  force. 

Rupture  of  the  Gestation  Sac.  —  Abortion  of  a  gravid  tube,  as 
described  in  the  foregoing  section,  is  a  very  common  termination  of 
tubal  pregnancy.  Failing  this  the  gestation  sac  almost  invariably  bursts, 
the  only  exception  being  the  very  rare  event  of  a  mole  lying  quiescent 
in  the  tube. 

Kupture  of  the  tube  will  1)0  discussed  in  the  sections  indicated  in 
the  subjoined  table  :  — 

1.  Primary  rupture  —  (a)  Intraperitoneal ;  (b)  extraperitoneal. 

2.  Secondary  rupture  —  (a)  Intraperitoneal ;  (b)  extraperitoneal. 


EXTRA-  UTERINE    GESTA  TION 


461 


Primary  Rupture.  — This  term  refers  to  the  rupture  of  the  tube  which, 
iu  the  majority  of  cases,  occurs  at  some  period  between  the  third  and 
tenth  week  after  impregnation,  and  is  rarely  deferred  beyond  the  twelfth 
week. 

The  predisposing  causes  of  rupture  are  the  gradual  thinning  of  the 


W^    '  OVARY. 


Fig.  186.  —  Fallopian  tube  and  ovary,  mole  and  corpus  luteuui  from  a  case  of  complete  tubal  abortion. 

{Nat.  xhe.) 

walls  of  the  gestation  sac  as  the  embryo  grows,  and  the  undue  dis- 
tension of  the  meuibraues  by  lu«morrhage.  jNIuret  has  pointed  out, 
in  a  very  careful  study  of  specimens,  that  the  thinning  is  especially 
marked  at  the  seat  of  implantation  of  the  chorionic  villi.  Rupture  is 
sometimes  produced  by  violence,  such  as  jumping  from  a  train,  stool,  or 
carriage ;  straining  during  vomiting  or  deftecation,  or  sexual  congress. 


462  SYSTEM   OF  GYNECOLOGY 

Before  considering  this  event  in  detail,  ^ve  may  for  a  moment  study 
the  relation  of  the  Fallopian  tube  to  the  mesometrium  (broad  ligament). 
The  health}"  tubes  in  the  human  female  occupy  the  free  borders  of  this 
structure,  and,  on  two-thirds  of  their  circumference,  are  invested  by  it ; 
indeed  the  tube  is  held  in  position  by  a  peritoneal  investment  resembling 
the  mesentery.  The  portion  of  the  mesometrium  adjacent  to  the  tube 
is  appropriately  termed  the  mesosalpinx. 

When  the  tube  becomes  enlarged  in  consequence  of  iiiflammation,  or 
dilated  by  an  embrj^o  growing  Avithin  its  lumen,  the  layers  of  the  meso- 
salpinx are  separated  by  the  enlarging  tube. 

This  separation  of  the  layers  of  the  mesosalpinx,  however,  does  not 
occur  along  the  whole  extent  of  the  tube,  but  is  restricted  mainly  to  its 
middle  third.  It  is  important  to  realise  this,  because  it  explains  the 
frequency  of  intraperitoneal  riqyture,  when  the  embryo  is  situated  in  the 
outer  third  of  the  tube.  The  anatomical  evidence  alone  leads  us  to  expect 
that  when  a  pregnant  tube  bursts,  the  chances  of  this  accident  including 
the  serous  covering  would  be  greatly  in  excess  when  the  rupture  takes 
place  in  the  uncovered  portion ;  and,  as  a  matter  of  fact,  intraperitoneal 
is  to  extraperitoneal  rupture  in  the  proportion  of  three  to  one. 

In  primary  intraperitoneal  rupture  the  embryo  and  its  membranes,  or 
a  mole  accompanied  by  a  variable  amount  of  blood,  may  be  discharged 
directly  into  the  coelom.  The  quantity  of  blood  extravasated  depends 
upon  the  date  of  rupture.  When  this  occurs  early,  the  blood  extrava- 
sated may  amount  to  a  few  ounces;  but  after  the  first  month  it  is 
usually  very  copious,  and  frequently  causes  death  in  a  few  hours.  When 
rapture  is  deferred  until  the  seventh  week  the  embryo  (or  the  mole)  is 
not  constantly  discharged  through  the  rent;  and  as  the  walls  of  the 
gestation  sac  are  prevented  from  contracting,  the  amount  of  blood  which 
escapes  is  often  very  large.  When  the  haemorrhage  is  moderate  in 
amount,  and  the  patient  escapes  the  immediate  dangers  incidental  to  the 
accident,  especially  shock,  the  effused  blood  may  undergo  partial  absorp- 
tion and  recovery  ensue.  When  the  bleeding  is  not  excessive,  the  blood 
collects  in  the  recto-vaginal  fossa  and  floats  up  the  coils  of  intestines. 
These,  with  the  omentum,  gradually  form  a  covering  to  the  fossa  by 
adhering  together ;  so  that  the  blood  in  the  pelvis  is  isolated  from  the 
general  peritoneal  cavity  (coilom).  Unless  haemorrhage  recur  the  fluid 
portion  of  the  blood  is  slowly  absorbed,  and  the  patient  recovers;  but 
convalescence  is  very  tardy. 

Taylor  has  reported  some  valuable  cases  in  which  he  demonstrates 
clearly  enough  that  in  some  instances  the  blood  undergoes  coagulation  in 
layers  and  foruis  a  sort  of  spurious  cyst.  In  my  experience  the  walls 
of  these  spurious  cavities  resemble  the  laminated  arrangement  familiar 
to  surgeons  in  the  parietes  of  a  hajmatocele  of  the  tunica  vaginalis  testis. 

Tlie  dangers  of  primary  intraperitoneal  rupture  are  :  —  i.  llapid  death 
from  luemorrhage.     ii.  A  fatal  result  from  repeated  hiemorrhage. 

Pritnary  ExtraperitoneMl  Rupture.  —  In  a  certain  proportion  of  cases 
the  tube  ruptures  through  tliat  portion  of  its  circumference  which  lies 


EXTRA-UTERINE    GESTATION  463 

between  the  separated  layers  of  the  mesosalpinx.  "When  this  happens 
the  mole  and  a  varying  amount  of  blood  are  forced  into  the  connective 
tissue  between  the  layers  of  the  mesometrium  (broad  ligament).  In  most 
cases  this  is  fortunate  for  the  patient,  as  the  bleeding  is  checked  by  the 
pressure  exerted  by  the  resistance  which  occurs  as  the  mesometric  tissue 
becomes  distended,  and  is  arrested  before  it  assumes  dangerous  propor- 
tions. Thus  the  blood  and  mole  are  entombed,  as  it  Avere,  in  the 
mesometrium,  and  rarely  cause  subsequent  trouble. 

Rupture  may  take  place  and  the  embryo  with  its  membranes  remain 
uninjui-ed  and  the  pregnancy  continue;  for,  no  longer  confined  within 
the  narrow  limits  of  the  tube,  it  begins  to  avail  itself  of  the  additional 
space  thus  offered,  and  burrows,  as  it  grows,  between  the  layers  of  the 
mesometrium. 

From  the  manner  in  which  this  mode  of  rupture  is  sometimes  de- 
scribed it  might  be  imagined  that  the  tube  splits,  and  that  the  products 
of  gestation  are  suddenly  discharged  from  the  tube  into  the  mesometrium. 
This  is  not  the  case,  or  the  pregnancy  would  in  every  instance  come  to 
an  end  from  the  dissociation  of  the  foetal  from  the  maternal  structures. 
So  far  as  I  have  been  able  to  study  the  morbid  anatomy  of  the  accident, 
the  slow  and  gradual  distension  of  the  tube  causes  it  to  thin  and  gradu- 
ally yield  in  the  part  of  its  circumference  uncovered  by  peritoneum  until 
an  opening  forms,  accompanied  by  sudden  hfemorrhage ;  this  produces 
collapse,  the  profundity  and  duration  of  which  depend  upon  the  amount 
of  blood  that  escapes.  This  artificial  opening  gradually  extends  until 
the  growing  embryo  and  placenta  make  their  Avay  into  the  new  area  of 
connective  tissue  thus  opened  up,  and  by  degrees  occupy  it,  unless  the 
life  of  the  embryo  be  terminated  by  renewed  heemorrhage. 

When  pregnancy  continues  in  this  way  it  is  spoken  of  as  a  "  meso- 
metric gestation,"  because  the  sac  is  formed  in  part  by  the  expanded 
Fallopian  tube  and  the  layers  of  peritoneum  forming  the  mesometrium. 

Dezeimeris  described  the  development  of  an  extra-uterine  foetus  in 
this  situation  as  far  back  as  1836,  and  Parry  draws  attention  to  it 
thus : — 

"  By  subperitoneo-pelvic  (sous-peritone-pelvienne)  pregnancy  Dezei- 
meris intended  to  designate  a  variety  in  which  the  o\iim,  after  quitting 
the  ovarian  vesicle,  did  not  enter  the  Fallopian  tube  nor  fall  into  the 
peritoneal  cavity,  but,  on  the  contrarj^,  passed  between  the  two  folds  of 
the  broad  ligament,  and  there  developed.  According  to  this  view  the 
product  of  conception  is  situated  outside  the  cavity  of  the  peritoneum. 
That  the  ovum  has  been  found  in  this  locality  cannot  be  doubted,  but 
when  such  is  the  case  there  is  every  reason  to  believe  that  it  reaches 
this  peculiar  situation  through  rupture  of  a  tubal  cyst,  in  which  the 
integrity  of  the  peritoneum  was  not  destroyed,  so  that  the  ovum  escaped 
between  the  two  layers  of  the  broad  ligament,  where  it  continued  to 
develop.  It  is  therefore  one  of  the  terminations  of  an  ordinary  tubal 
gestation." 

Subsequent  observotion  on  this  head  has  not  only  justified  Parry's 


464  SYSTEM  OF  GYNECOLOGY 

opinion,  but  demonstrated  the  fact  that  in  all  tubal  pregnancies  which 
survive  the  primary  rupture  and  continue  their  development,  the  gesta- 
tion sac  is  formed  in  part  by  the  expanded  tube,  but  mainly  by  the  layers 
of  the  niesometrium.  The  proper  appreciation  of  this  fact  has  done 
much  to  simplify  our  knowledge  of  tubal  pregnancy ;  and  no  one  has 
more  strongly  insisted  upon  its  correctness  than  Lawson  Tait. 

It  is  clear  from  a  study  of  Dezeimeris'  paper  that  his  observation 
was  of  a  very  casual  sort,  and  he  certainly  failed  to  appreciate  its 
importance. 

The  Placenta  and  Decidua.  —  In  tubal  gestation  the  placenta  is  liable 
to  many  vicissitudes  which  very  materially  influence  the  life  of  the 
foetus,  as  well  as  that  of  the  mother ;  and  as  in  many  cases  it  is  a  source 
of  anxiety  to  the  surgeon,  it  is  imperative  upon  those  who  may  be  called 
upon  to  deal  clinically  with  tubal  gestation  to  consider  the  subject  with 
more  than  ordinary  care. 

The  placenta  formed  in  tubal  gestation  differs  in  several  particulars 
from  one  developed  in  the  uterus.  In  normal  gestation  the  uterine 
mucous  membrane  is  supposed  to  take  a  large  and  important  share  in 
forming  the  placenta ;  but,  so  far  as  I  can  judge  from  my  own  observa- 
tions, the  tubal  mucous  membrane  plays  a  very  insignihcant  part  when 
pregnancy  occurs  in  the  tube. 

The  fully  developed  uterine  placenta  is  composed  of  parts  derived 
from  the  maternal  and  foetal  tissues  in  nearly  equal  pai-ts;  a  tubal 
placenta  is  mainly  if  not  entirely  derived  from  the  foetal  tissues. 

Clarence  Webster  has  endeavoured  to  show  that  certain  changes 
which  he  describes  in  the  deep  layers  of  the  mucosa  of  gravid  tubes 
represent  a  decidual  formation.  From  a  thorough,  careful,  and  repeated 
microscopical  examination  of  gravid  tubes  in  exceptionally  early  stages 
of  pregnancy  I  have  failed  to  find  anything  that  can  be  regarded  as  a 
tubal  decidua,  certainly  nothing  that  is  cast  off  in  the  form  of  a  mem- 
brane, and  this  is  an  essential  qualification  for  a  decidua. 

Tlie  Uterine  Decidua. — It  is  a  curious  circumstance  in  tubal  preg- 
nancy that,  though  no  decidua  forms  in  the  tube,  a  decidua  forms  in  the 
uterus.  Few  facts  have  been  so  much  disputed  as  this,  and  the  discussions 
will  be  found  in  Parry's  classical  work.  The  conclusions  of  Parry  have 
been  confirmed  by  those  who  have  studied  the  subject  in  recent  years. 

My  own  observations  are  so  thoroughly  consonant  with  those  of 
Parry  that  his  views  will  be  given  in  his  own  words :  — 

"1.  In  all  varieties  of  extra-uterine  pregnancy  a  decidua  forms  in 
the  uterine  cavity,  as  in  normal  gestation,  but  none  is  found  in  the  tube. 

"2.  The  d(u;idiia  is  rarely  retained  until  the  completion  of  gestation, 
and  thrown  off  during  false  labour.  More  frequently,  if  the  patient  goes 
to  term,  it  is  discharged  during  the  early  periods  of  pregnancy  in  small 
fragments  and  without  producing  pain;  or  else  it  is  expelled  en  masse 
with  symptoms  of  miscarriage. 

"3.  The  absence  of  a  uterine  decidua  when  death  has  occurred  from 
rupture  of  the  cyst,  even  in  the  early  stages  of  pregnancy,  is  not  proof 


EX  TRA-  U  TERINE    GES  TA  TION 


465 


that  the  membrane  has  not  been  formed,  but  simply  that  it  has  been 
expelled  before  the  death  of  the  foetus." 

It  is  an  interesting  and  curious  fact  that  when  pregnancy  occurs  in 
cne-half  of  a  bicorned  uterus,  a  decidua  forms  in  the  unimpregnated 
cornu.  I  have  myself  observed  that  a  similar  condition  holds  good  in 
animals  normally  possessed  of  bicorned  uteri  (for  example,  in  ungulates 
and  lemurs).  In  normal  pregnancy  no  decidua  forms  in  the  Fallopian 
tubes  or  in  the  cervical  canal.  It  is  now  well  established  that  the  destruc- 
tive changes  which  occur  in  the  mucous  membrane  of  the  genital  tract 
in  association  with  menstruation  are  limited  to  the  lining  of  the  cavity 
of  the  uterus ;  and  that  the  formation  of  a  true  decidua  is  limited  to 
that  part  of  the  genital  tract  which  undergoes  the  destructive  changes 
associated  with  menstruation  and  rut. 

It  is  important  not  to  confound  a  decidua  of  j)regnancy  with  a  decidua 
occurring  in  what  is  called  membranous  dys- 
menorrhoea.  Menstrual  deciduce  rarely  exceed 
2  or  3  cm.  in  length,  and  are  scarcely  2  mm. 
in  thickness.  As  a  rule  they  are  translucent, 
and  rarely  passed  entire.  The  deciduce  ofjjreg- 
nancy  are  larger,  and  vary  in  thickness  6  to 
8  mm.  They  may  be  described  as  bags  re- 
sembling in  outline  an  isosceles  triangle.  The 
base  corresponds  to  the  fundus  of  the  uterus, 
and  the  apex  to  the  internal  opening  of  the 
cervical  canal.  At  each  angle  of  the  triangle 
there  is  an  opening.  Those  at  the  basal 
angles  correspond  to  the  Fallopian  tubes,  and 
the  apical  orifice  to  the  cervical  canal.  The 
outer  aspect  is  shaggy,  and  the  inner  surface  is  dotted  with  the  orifices 
of  uterine  glands.  The  angle  corresponding  to  the  internal  orifice  of 
the  cervical  canal  is  often  represented  by  a  large  opening  (Fig.  137). 

Up  to  the  period  of  primary  rupture  the  formation  of  the  placenta 
has  been  proceeding  in  relation  with  the  mucous  membrane  of  the  Fallo- 
pian tube ;  but  after  this  event,  if  the  disturbance  of  the  parts  be  not  so 
great  as  to  terminate  the  pregnancy,  the  course  of  events  is  modified  in 
a  remarkable  manner.  We  are  indebted  largely  to  the  admirable  inves- 
tigations of  Drs.  Berry  Hart  and  Carter  for  the  facts  upon  which  this 
account  is  based.  After  primary  rupture  of  the  tube  the  embryo  and 
placenta  (when  the  development  is  sufficiently  advanced)  gradually  occupy 
a  sac  formed  by  the  expanded  tube  and  separated  layers  of  the  meso- 
metrium,  the  floor  of  this  space  being  formed  by  connective  tissue  and 
the  levator  ani  muscle. 

The  ultimate  effects  of  this  gradual  dislocation  of  the  embryo  and 
placenta  depend  mainly  upon  the  original  position  of  the  placenta. 
Dr.  Hart  points  out  that  if  the  embryo  lie  above  the  placenta,  the 
latter  becomes  depressed  between  the  layers  of  the  mesometrium  until 
it  is  arrested  by  the  pelvic  floor.     If,  on  the  contrar}',  the  embryo  lies 


Fig.  137. — Uterine  decidua:  from  a 
case  of  tubal  pregnancy.   {Xat.  size. ) 


2h 


466 


SYSTEM  OF  GYNECOLOGY 


below  the  placenta,  the  embryo  in  its  membranes  burrows  between  the 
layers  of  the  mesometrium,  and  the  placenta  is  pushed  up  by  the  growing 
embryo  until  it  lies  high  in  the  abdomen  (Figs.  138  and  139).  He  has 
had  opportunities  of  investigating  the  structure  of  these  extra-uterine 
placentae,  and  points  out  that  in  tubal  gestation  the  villi  lie  embedded 
in  decidual  cells,  and  no  intervillous  sinus  system  seems  to  exist.  Large 
sinuses,  however,  form  in  the  muscular  wall.  The  villi  are  well  formed, 
and  are  covered  with  perfect  epithelium.  The  decidual  cells  are  large, 
and  have  a  large  nucleus  and  nucleolus.  When  the  placenta  is  displaced 
into  the  mesometric  tissue  —  and  we  must  bear  in  mind  that  this  displace- 
ment occurs   gradually  —  the   placental   structure   becomes   seriously 


Levator  ani 


Fio.  138. —Transverse  section  of  the  pelvis  of  a  woman  with  an  embryo  and  placenta  of  the  fourth 
month  of  g-estation  occupying  the  riglit  mesometrium.     (After  Berry  Hart.) 

damaged.  The  villi  are  less  perfect  in  contour,  blood  extravasation  is 
present,  Vjlood  crystals  are  abundant,  and  the  decidual  cells  few  and 
less  perfect. 

Dr.  Hart's  observations  lead  him  to  conclude,  that  on  the  displace- 
ment of  the  placenta  from  mucous  membrane  to  connective  tissue, 
the  placenta  is  gradually  reduced  to  a  mass  of  compressed  villi,  the 
serotina  is  destroyed,  and  is  replaced  by  blood  crystals  and  organising 
Ijlood-clot.  The  least  damage  is  sustained  ]jy  the  placenta  when  the 
embryo  is  situated  above  it,  because  under  such  conditions  it  undergoes 
the  minimum  amount  of  displacement.  The  extreme  disorganisation  to 
which  the  placenta  is  lial^le  when  it  forms  the  roof  of  the  gestation  sac 
may  be  studied  even  in  the  early  stage  of  the  pregnancy. 


EX  TEA-  U  7  'ERINE    GES  TA  TION 


467 


It  must  be  obvious  that  a  placenta  when  displaced  in  this  way  must 
have  its  function  very  seriously  hampered  in  comparison  with  one  firmly 
deposited  on  the  floor  of  the  pelvis.  It  has  been  demonstrated  histo- 
logically that  there  is  great  damage  produced  by  this  slow  migration. 

It  is  of  the  utmost  importance  to  appreciate  correctly  the  structural 
alterations  Avliich  occur  in  the  placenta,  consequent  upon  these  remark- 


Seat  of  rupture 
Blood 


Peritoneum 


Peritoneum 


Fig.  139.  —  Sagittal  section   of  a  cadaver,  with  a  iiiesomctrium    prcffnancy  at  term 
e.Ktreme  displaceiueiit  of  tlio  iilaceiita.     (After  Berry  Hart.) 


it  indicates  the 


able  displacements  to  which  it  is  subject ;  they  exert  a  great  influence 
on  the  subsequent  liistory  of  the  pregnancy,  greatly  imperil  the  life  of 
the  mother,  and  in  most  cases  are  disastrous  to  the  life  of  the  fostus. 

The  danger  in  which  such  displacements  of  the  placenta  place  the 
mother  is  this :  —  The  constant  tension  to  which  the  peritoneum  cover- 
ing the  gestation  sac  is  subject  may  at  any  time  cause  it  to  yield,  and 
lead  to  partial  detachment  of  the  placenta,  and  as  a  consequence  to 


468  SYSTEM  OF  GYNECOLOGY 

severe  haemorrhage,  which  may  take  place  into  the  gestation  sac,  or 
more  probably  into  the  coelom.  Such  haemorrhage  in  the  late  stages  of 
these  pregnancies  is  almost  invariably  fatal.  Indeed,  a  woman  with  a 
mesometric  pregnancy,  with  the  placenta  situated  above  the  foetus,  runs 
a  far  greater  risk  of  losing  her  life  than  when  she  is  the  victim  of  the 
dreaded  condition  termed  })lacenta  jyrcevia. 

Tlie  Effects  of  Placental  Migration  on  the  Foetus.  —  We  have  seen 
already  that  tubal  placentcC  are  less  perfect  organs  than  uterine  placentae. 
Even  when  a  tubal  placenta  lies  below  the  embryo  after  rupture,  its 
structure  is  so  damaged  as  to  make  it  an  ineflBcient  respiratory  organ ; 
hence,  when  it  is  situated  above  the  embryo,  it  must  be  much  less 
.  adequate  to  the  needs  of  the  foetus,  and  subject  to  the  grievous  vicissi- 
tudes which  have  been  already  mentioned. 

The  results  on  the  embryo  are  very  manifest.  A  foetus  the  product 
of  a  tubal  gestation  is  a  very  unsatisfactory  individual.  Even  when 
rescued  by  the  surgeon  at  or  near  time,  it  rarely  survives  longer  than  a 
few  days  or  weeks.  In  many  cases  these  infants  are  ill-formed,  and 
present  hydrocephalus,  club-foot,  spina  bifida,  ectopia  of  the  viscera,  or 
similar  deformity ;  and,  even  when  normal  in  shape,  they  are  exceed- 
ingly defective  in  size.  In  one  instance  a  tubal  sac  contained  two 
embryos  measuring  11  cm.  in  length,  united  by  a  band  in  the  thoracic 
region  (Thoracopagus). 

Secondary  Riqyture.  —  When  the  pregnancy  continues  between  the 
layers  of  the  (mesometrium)  broad  ligament,  the  gestation  sac  may 
rupture  at  any  moment;  and  the  risk  of  this  accident,  so  far  as  Ave  can 
judge  at  present,  is  much  greater  when  the  placenta  is  situated  above 
the  foetus.  As  the  pregnancy  progresses,  the  peritoneum  forming  the 
sac  becomes  stretched  and  stripped  from  adjacent  parts  and  from  the 
viscera.  Sometimes,  as  the  sac  extends  into  the  abdomen,  it  will  strip 
the  peritoneum  from  the  anterior  abdominal  wall,  as  in  the  case  of  an 
over-distended  bladder,  only  to  a  much  greater  extent.  When  the 
serous  membrane  is  stripped  from  the  posterior  aspect  of  the  pelvis, 
the  rectum  may  be  deprived  of  its  serous  investment,  as  well  as  the 
posterior  surface  of  the  uterus,  the  fcjetus  and  placenta  insinuating 
themselves  between  these  parts  beneath  the  peritoneum. 

At  any  period  between  the  twelfth  week  and  term  the  gradually 
thinning  gestation  sac  may  rupture.  The  effects  of  this  accident  vary. 
When  the  rent  involves  the  placenta,  as  it  is  almost  certain  to  do  when 
this  organ  is  situated  above  the  foetus,  and  the  gestation  has  advanced 
beyond  the  mid-period  of  pregnancy,  terrible  haemorrhage  and  a  speedy 
death  are  the  usual  consequence ;  before  this  date  the  haemorrhage  may 
not  always  be  so  severe,  and  opportunities  for  surgical  intervention  may 
be  found.  When  the  sac  bursts  into  the  peritoneum  in  this  w<ay,  it  is 
sj)oken  of  as  secondary  intraperitoneal  rupture. 

When  the  placenta  occupies  the  pelvis,  and  the  f(i;tus  the  abdominal 
portion  of  the  sac,  the  latter  may  become  so  slowly  thinned  that  at  last 
it  yields,  and  the  ffjbtus  disports  itself  among  the  intestines. 


EXTRA-UTERINE    GESTATION  469 

It  must  be  remembered  that  secondary  rupture  may  be  indefinitely 
delayed,  and  in  some  cases  never  occurs.  The  patient  goes  to  term, 
passes  through  a  spurious  labour,  the  liquor  amnii  is  absorbed,  the 
placenta  disappears,  and  the  existence  of  an  extra-uterine  pregnancy  is 
never  suspected  until  a  mummified  foetus  or  a  lithopaidion  is  discovered 
at  the  autopsy  (see  p.  472). 

Of  the  two  forms  of  secondary  rupture,  the  intraperitoneal  variety 
may  occur  at  any  date  between  the  twelfth  week  and  term. 

Secondary  intraperitoneal  rupture  near  or  at  term  must  be  discussed 
more  fully,  because  these  are  the  cases  which  tend  to  perpetuate  the 
belief  that  fertilised  ova  may  tumble  into  the  coelom  and  engraft 
themselves  upon  the  serous  membrane  and  develop.  A  critical  inquiry 
into  this  matter  has  convinced  me  that  there  is  no  case  on  record  which 
can  be  cited  as  decisive  proof  of  this  occurrence.  There  is  no  such 
condition  as  a  primary  peritoneal  pregnancy.  All  forms  of  extra-uterine 
gestation  pass  their  primary  stages  in  the  Fallopian  tube. 

I  am  of  opinion  that  the  so-called  primary  abdominal  pregnancies  are 
primary  tubal ;  gradually  the  tube  opens  out  into  the  broad  ligament, 
and  as  the  pregnancy  progresses  to  term  the  walls  of  the  gestation  sac 
rupture,  and  the  foetus  escapes  into  the  coelom,  as  in  the  remarkable  case 
recorded  by  Mr.  Jessop  :  — 

"  A  woman  twenty-six  years  of  age  believed  herself  two  months 
pregnant ;  she  was  suddenly  seized  with  violent  pain  in  the  right  side  of 
the  belly,  which  caused  her  to  faint.  From  the  effects  of  this  trouble 
she  kept  her  bed  two  months.  Five  months  later,  at  a  consultation,  it 
was  decided  that  she  was  a  victim  of  extra-uterine  gestation,  and  she  was 
admitted  into  the  Leeds  Infirmary.  As  the  woman  was  in  a  critical 
condition  abdominal  section  was  performed  without  delay.  On  cutting 
through  the  anterior  wall  of  the  belly,  the  breech  and  back  of  a  child 
thickly  coated  with  vernix  caseosa  came  into  view.  The  child  had 
lodged  in  the  midst  of  the  bowels,  free  in  the  cavity  of  the  abdomen.  Xo 
trace  of  cyst  or  membrane  could  be  discovered.  The  placenta  Avas  seen 
covering  the  inlet  of  the  pelvis,  like  the  lid  of  a  pot,  and  extending  some 
distance  posteriorly  above  the  brim,  where  it  apparently  had  an  attach- 
ment to  the  large  bowel  and  posterior  abdominal  wall.  The  patient 
recovered  from  the  operation,  and  the  child  lived  for  eleven  months." 

From  this  case  nothing  positive  can  be  inferred;  fortunately  the 
woman  recovered,  and  the  relation  of  the  placenta  to  the  gestation  sac 
and  the  condition  of  the  Fallopian  tubes  could  not  be  ascertained. 

Similar  cases  have  been  described  by  Champneys,  Taylor,  and  others. 

I  have  had  one  excellent  opportunity  of  dissecting  the  pelvis  of  a 
woman  Avho  died  after  the  removal  of  an  extra-uterine  fatiis  which  had 
escaped  from  the  gestation  sac  among  the  intestines.  I  was  able  to  isolate 
the  displaced  layers  of  the  right  broad  ligament  forming  the  gestation 
sac,  in  which  a  large  piece  of  amnion  was  retained.  The  placenta  had 
occupied  the  pelvis  and  part  of  the  posterior  wall  of  the  uterus  beneath 
the  peritoneum.     The  corresponding  tube  and  ovary  were  not  detected. 


47° 


SYSTEM  OF  GYNECOLOGY 


Tubo-uterine  Gestation.  —  When  an  oosperm  lodges  and  develops  in 
the  section  of  the  Fallopian  tube  which  traverses  the  uterine  wall,  the 
gestation  is  termed  tubo-uterine.  This  variety  runs  a  somewhat  dif- 
ferent course  from  the  purely  tubal  form. 

Tubo-uterine  gestation  is  somewhat  rare  ;  many  specimens  described 
as  belonging  to  this  class  turn  out  on  critical  examination  to  be  speci- 
mens of  corniial  pregnancy. 

The  occurrence  of  tubo-uterine  gestation  admits  of  no  doubt  Avhat- 
ever ;  and,  fortunately,  a  few  specimens  exist  of  this  accident  which 
demonstrate   its   absolute   independence  of  cornual   pregnancy.     Two 


Fig.  140. — Tubo-uterine  gestation.    (Museum,  (Juy's  Hospital.) 


specimen.s  —  one  preserved  in  the  museum  of  Guy's  Hospital,  and  the 
other  in  the  museum  of  the  Royal  College  of  Surgeons,  which  has  had 
the  advantage  of  careful  investigation  by  Mr.  Doran  —  arc  the  most 
satisfactory  and  easily  accessible  examples  in  London. 

The  specimen  at  (xuy's  is  carefully  desci-ibod  in  tlic  Report  of  that 
hospital  for  18G0  by  \)v.  Braxton  J  licks. 

Doi'an  has  described  in  detail  a  uterus  obtained  from  a  woman  aged 
thii-ty-two  years,  who  died  from  haemorrhage  in  about  ten  hours  after 
rupture  of  the  sac  of  a  tubo-uterine  gestation.  An  embryo  enveloped  in 
membranes,  and  corresponding  to  the  second  month  of  development,  was 
found  floating  in  blood  in  the  abdominal  cavity. 


EX  TRA-  UTERINE    GES  TA  TION 


471 


Tubo-uterine  gestation  differs  in  its  course,  anatomy,  and  modes  of 
termination  from  the  purely  tubal  form.  In  tubal  gestation  primary 
rupture  usually  occurs  about  the  eighth,  and  is  rarely  deferred  beyond 
the  twelfth  week ;  in  the  tubo-uterine  variety  it  may  be  delayed  much 
beyond  this  date. 

The  date  of  rupture  in  four  cases  is  given  in  the  subjoined  table  — 

Braxton  Hicks.  —  The  development  had  probably  proceeded  to  the  end  of  the 

fourth  month. 
Lawson  Tait.  —  The  patient  thought  she  had  turned  the  fourth  month. 
Doran.  —  About  the  end  of  the  second  month. 
Author.  —  About  the  fifth  week. 

The  sac  of  a  tubo-uterine  gestation  may  rupture  in  two  directions : 
It  may  burst  into  the  coelom,  and  be  rapidly  fatal ;  or  into  the 
uterine  cavity,  and  be  discharged  like  an  ordinary  uterine  conception. 
It  must  be  remembered  that  in  this  variety  the  sac  does  not  rupture  in 
such  a  way  as  to  allow  of  the  embryo  being  dislocated  between  the  layers 
of  the  mesometriiun. 

An  examination  of  the  clinical  details  of  cases  of  undoubted  tubo- 
uterine  gestation  indicates  that  intraperitoneal  rupture  of  the  sac  is  more 
rapidly  fatal  than  the  tubal  form;  and  that  this  is  due  to  the  greater 
amount  of  haemorrhage,  because  not  only  are  the  walls  of  the  gestation 
sac  thicker,  but  the  rent  often  extends  to  and  involves  the  uterine  Avail. 

As  a  means  of  ready  reference  the  points  in  which  the  two  varieties 
of  tubal  gestation  differ  from  each  other  are  arranged  in  tabular  form ;  — 


Tubal. 

Tubo-uterine. 

Frequency. 

Very  common. 

Very  rare. 

Gestation  sac. 

Walls  are  very  thin. 

Walls  very  thick. 

Termination. 

(ce)       Intraperitoneal 

(a)      Intraperitoneal 

rupture. 

rupture. 

{h)  May  rupture  into 

(6)  jNIay  rupture  into 

tlie   mesometric 

uterine  cavity,  and 

space. 

be     discharged 

(c)  May  abort. 

through  the  vagina. 

Date   of    primary 

At  any  date  from  the 

At  any  date  from  the 

rupture  or  abor- 

3rd to  12th  week. 

5th     to     the     20th 

tion. 

week. 

Although  in  many  examples  of  tubo-uterine  gestation  primary  rupture 
may  be  delayed  longer  than  in  the  pvirely  tubal  form,  nevertheless  the 
sac  sometimes  bursts  very  early.  In  these  cases  death  from  lui}morrhage 
may  follow  within  a  few  hours. 

Ovarian  Pregnancy.  —  In  writings  on  extra-uterine  gestation  it  has 
been  for  many  years  the  custom  to  describe  a  variety  known  as  *'  ovarian 
pregnancy,"  an  event  believed  to  be  due  to  the  fertilisation  of  an  ovum 
before  its  escape  from  the  ovarian  follicle. 


472  syST£M  OF  GY.V.-ECOLOGY 

It  is  extraordinary  tliat  belief  in  the  occurrence  of  ovarian  pregnancy 
should  have  obtained  currency.  Those  who  care  to  take  the  trouble  to 
study  the  evidence  in  support  of  it,  especially  that  collected  by  Campbell, 
will  find  that  some  of  the  supposed  examples  were  as  a  matter  of  fact 
ovarian  dermoids,  and  that  the  others  were  based  on  the  most  flimsy 
examination. 

In  the  cases  of  supposed  ovarian  pregnancy  published  by  observers  of 
repute,  like  Martin  and  Leopold,  the  foetus  in  each  instance  had  been 
many  years  sequestered  in  the  mesometrium ;  hence  it  is  impossible  to 
infer  the  relation  of  the  gestation  sac  to  the  ovary  with  any  certainty. 

In  some  English  cases  reported  as  ovarian  pregnancy  the  opinion  as 
to  their  situation  in  the  ovary  was  based  on  the  circumstance  that  at 
the  autopsy  the  ovary  was  not  seen !  Until  some  specimen  is  forth- 
coming in  which  an  early  embryo,  in  its  membranes,  can  be  demonstrated 
in  a  sac  inside  the  ovary  we  need  not  trouble  ourselves  to  discuss  ovarian 
pregnancy. 

Retention  of  the  FcEtus.  —  In  tubal  pregnancy  the  life  of  the  embryo, 
as  has  been  shown  in  a  preceding  section,  is  very  precarious.  Yet  in 
the  face  of  all  these  possibilities  the  gestation  may  run  on  to  term. 
Then  symptoms  of  labour  set  in,  and  as  delivery  by  the  natural  channels 
is  impossible,  the  gestation  sac  may  burst  into  the  coelom,  with  all 
the  attendant  evils  of  this  event.  If  it  escape  this  catastrophe  the 
foetus  dies,  and  the  body  may  either  remain  quiescent  or  may  give  rise 
to  various  forms  of  disturbance. 

In  the  more  fortunate  cases  the  unavailing  labour  is  (p.  475)  followed 
by  absorption  of  the  liquor  amnii,  and  the  tissues  of  the  foetus  may  become 
mummified,  or  they  may  be  partially  calcified  to  form  a  lithopsedion ;  the 
soft  parts  may  be  converted  into  adipocere,  or  the  tissues  may  otherwise 
decompose.     The  placental  tissues  gradually  and  completely  disappear. 

Mummification.  —  To  produce  this  state  the  fluid  parts  become  ab- 
sorbed, and  the  soft  parts  are  converted  into  dry  tissue,  so  that  the  foetus 
resemVjles  a  mummy,  or  the  dried  cats  so  commonly  found  under  the 
floors  of  old  dwellings. 

The  length  of  time  an  extra-uterine  foetus  may  be  retained  is  some- 
times very  great.  In  Cheston's  celebrated  case  a  lithopsedion  was 
retained  fifty-two  years.  Dr.  Barnes  reported  a  case  in  which  a 
lithopcfidioii  was  retained  forty-two  years. 

A  retained  foitus  may  give  trouble  at  any  time.  Pathogenetic  micro- 
organisms obtain  entrance  to  the  sac  from  some  of  the  adjacent  hollow 
viscera  (rectum,  intestines,  bladder,  etc.)  and  establish  suppuration.  The 
pus  may  find  its  way  through  the  abdominal  wall  or  penetrate  into  the 
vagina,  uterus,  rectum,  or  bladder.  Through  fistulte  thus  formed  frag- 
ments of  fajtal  tissues  from  time  to  time  escape.  It  has  been  demonstrated 
that  a  woman  may  liavc;  a  lithopijedion  or  a  macerated  fojtal  skeleton  in 
her  iiicsoiiiotrium  and  yet  conccnve  in  the  uterus. 

The  Diagnosis  of  Tubal  Pregnancy.  —  The  symptoms  of  tubal  gesta- 
tion  vary  considerably  according  to  the  stage  to  which  gestation  has 


EXTRA-UTERINE    GESTATION  473 

advanced.  It  will  be  necessary,  therefore,  to  deal  with  it  in  the  following 
stages :  — 

i.  Before  primary  rupture  or  abortion ;  ii.  At  the  time  of  primary 
rupture  or  abortion ;  iii.  From  primary  rupture  to  term  ;  iv.  After 
term. 

Before  proceeding  to  discuss  the  signs  which  occur  during  each  of 
these  stages,  it  is  necessary  to  point  out  that  the  patient  is  some- 
times aware  that  she  is  pregnant.  In  many  cases,  however,  she  is  not 
aware  of  the  fact,  and  the  practitioner  is  often  deceived  by  the  absence 
of  the  usual  signs  of  gestation,  such  as  fulness  of  the  breasts  and 
amenorrhcsa.  The  breast  signs  are  very  variable  in  tubal  gestation. 
In  many  cases  they  are  absent  even  when  the  pregnancy  has  gone  on  to 
the  fifth  month ;  in  others  the  signs  of  pregnancy  are  as  clear  and  as 
marked  as  in  normal  gestation.  In  one  of  my  cases  milk  was  present  in 
one  breast  only,  and  that  was  on  the  same  side  as  the  gravid  tube. 
Speaking  generally,  the  absence  of  the  usual  signs  of  pregnancy  do  not 
negative  the  existence  of  tubal  gestation ;  on  the  other  hand  their  pres- 
ence is  valuable,  and  may  lead  to  a  correct  diagnosis. 

i.  Before  Primary  Riqjture. — Gravid  tubes  have  in  many  instances 
been  removed  before  primary  rupture  or  abortion ;  but  in  nearly  all  the 
instances  recorded  before  1891  the  operations  were  undertaken  for  the 
purpose  of  removing  diseased  tubes  :  on  examination  of  the  tubes  after 
removal  the  fact  that  they  were  gravid  was  revealed.  Since  this  date 
the  pathology  of  the  early  stages  of  tubal  pregnancy  has  been  better 
understood,  and  a  clear  distinction  recognised  between  a  gravid  tube  and 
ahsematosalpinx.  Many  cases  have  accordingly  been  published  in  which 
a  correct  diagnosis  was  made  before  the  operation  was  undertaken. 
This  is  very  gratifying,  for  it  is  a  matter  of  the  utmost  importance  to  the 
patient,  as  it  spares  her  the  awful  peril  which  attends  the  rupture  of  the 
tube.  The  chief  points  in  this  stage  are  that  a  woman  previously 
regular  gives  a  definite  history  of  a  missed  menstrual  period;  soon 
afterwards  she  suffers  from  pelvic  pain  which  induces  her  to  seek 
advice ;  on  examination  an  enlarged  Fallopian  tube  is  detected.  If 
there  be  no  history  of  old  tubal  disease,  or  any  fact  in  the  history  of 
the  patient  suggesting  septic  endometritis  or  gonorrhoea,  then  the  pre- 
sumption is  in  favour  of  a  gravid  tube. 

ii.  Friinanj  liuptnre. — In  tubal  gestation  the  sac  ruptures  or  abor- 
tion occurs  at  some  time  before  the  twelfth  week.  The  effect  upon 
the  patient  depends  upon  the  seat  of  rupture.  When  the  rupture 
takes  place  between  the  layers  of  the  mesometrium  the  symptoms  will, 
as  a  rule,  be  less  severe  than  when  the  tube  bursts  into  the  peritoneum. 
The  pressure  exercised  by  the  blood  extravasated  into  the  tissues  of 
the  mesometrium  tends  to  check  haemorrhage,  whereas  the  cadom  will 
hold  all  the  blood  the  patient  possesses,  and  yet  ])roduce  no  haemostatic 
effect  by  pressure. 

The  signs  of  intraperitoneal  rupture  are  those  characteristic  of 
internal  haemorrhage.     The  patient  complains  of  a  sudden  feeling  as  if 


474  SYSTEM  OF  GYNECOLOGY 

"  something  had  given  way,"  and  this  is  followed  by  general  pallor  and 
faintness ;  the  voice  is  reduced  to  a  faint  Avhisper ;  the  respiration  is 
sighing;  the  temperature  depressed;  the  pulse  rapid  and  feeble;  and 
vomiting  usually  sets  in.     In  some  cases  death  ensues  in  a  few  hours. 

Should  the  patient  recover  from  the  shock,  she  will  sometimes  state 
that  she  suspected  herself  to  be  pregnant.  The  symptoms  of  rupture 
are  often  accompanied  by  hasmorrhage  from  the  vagina ;  and  shreds  of 
decidua  are  passed,  so  that  the  case  in  many  points  resembles  early 
uterine  abortion,  and  is  occasionally  mistaken  for  it.  Error  in  such 
circumstances  may  be  avoided  by  examining  the  shreds  discharged  from 
the  uterus  ;  if  they  are  found  to  be  chorionic  villi  the  pregnancy  is  clearly 
uterine.     This  simple  test  has  been  useful  to  me  on  several  occasions. 

The  rapidity  with  which  the  rupture  of  a  gravid  tube  will  sometimes 
destroy  life  has  caused  more  than  one  writer  to  describe  this  accident  "as 
one  of  the  most  dreadful  calamities  to  which  women  can  be  subjeeted." 
Indeed,  it  may  be  so  rapidly  fatal  that  in  many  recorded  cases  death  was 
attributed  to  poisoning,  until  dissection,  instituted  in  many  instances  by 
the  coroner,  revealed  the  true  cause  of  death.  In  1880  a  well-known 
English  actress  was  taking  an  ice  at  a  cafe  in  the  Bois  de  Boulogne  when 
she  suddenly  died.  Poisoning  was  suspected,  and  the  corpse  was  sent  to 
the  morgue.  At  the  autopsy  the  stomach  and  digestive  organs  Avere 
examined  for  poison.  jSTo  traces  of  poison  were  found,  but  a  gravid  tube 
Avhich  had  burst. 

An  analysis  of  many  careful  records,  and  the  inspection  of  specimens 
of  gravid  tubes,  demonstrate  that  the  most  dangerous  cases  are  those  in 
which  the  embryo  or  mole  is  lodged  in  the  uterine  or  inner  third  of  the 
tube.     Death  sometimes  follows  rupture  in  three  or  four  hours. 

In  some  of  the  recorded  cases  rupture  occurred  soon  after  the  patient 
had  retired  to  bed.  On  inquiry  in  one  case  I  ascertained  that  sexual 
congress  determined  the  rupture  of  the  gestation  sac. 

It  is  important  to  bear  in  mind  that  the  severe  disturbance  which  is 
usually  set  up  by  primary  intraperitoneal  rupture  of  a  gravid  tube  is 
simulated  by  lesions  of  other  abdominal  viscera ;  for  example,  by  per- 
forating ulcer  of  the  stomach,  duodenum,  small  intestine,  or  vermiform 
appendix;  rupture  of  a  pyosalpinx ;  acute  axial  rotation  of  an  ovarian 
tumour ;  acute  intestinal  obstruction ;  renal  colic,  and  biliary  colic  when 
unaccompanied  by  jaundice. 

On  the  other  hand,  the  profound  shock  which  usually  accompanies 
the  bursting  of  a  gravid  tube  has  been  confounded  with  each  of  the 
above-mentioned  lesions.  Malherbe  reported  the  details  of  a  case  in 
which  a  woman  thirty-four  years  of  age  was  submitted  to  operation  for 
supposed  strangulated  inguinal  hernia.  On  opening  the  sac  it  was 
found  filled  with  blood;  the  parietes  were  freely  incised,  and  a  gravid 
tul)e  which  had  burst  was  found  and  removed. 

iii.  From  Priraary  ItnpLura  to  Term.  —  From  the  third  month  onwards 
the  leading  .nigns  of  tubal  yeslation  may  be  summarised  thus  :  — 

(a)  Amenorrhoea  is  occasionally  found;  frequently  there  is  hsemor- 


EXTRA-UTERINE    GESTATION  475 

rhage  from  the  uterus,  occurring  at  irregular  intervals,  accompanied  by 
the  escape  of  decidual  membrane :  this  is  a  valuable  diagnostic  sign 
when  associated  with  the  physical  signs  of  a  tumour  outside  the  uterus. 
It  is  even  more  valuable  if  the  patient  have  missed  one  or  two  periods. 
(6)  There  may  or  may  not  be  milk  in  the  breasts.  Its  presence  is 
a  valuable  indication.  From  its  absence  nothing  to  the  point  can  be 
inferred. 

(c)  The  uterus  is  slightly  enlarged ;  the  os  is  usually  soft,  as  in  nor- 
mal pregnancy,  and  patulous. 

(d)  A  large  and  gradually  increasing  swelling  exists  to  one  side  and 
behind  the  uterus.  Occasionally  the  foetal  heart  can  be  heard,  and  in 
advanced  cases  the  outlines  of  the  foetus  may  be  distinguished. 

(e)  When  a  woman  in  whom  the  existence  of  tubal  gestation  is 
suspected  is  suddenly  seized  with  collapse  and  all  the  signs  of  internal 
bleeding,  it  is  indicative  of  rupture  of  the  gestation  sac. 

(/)  Tubal  pregnancy  is  very  apt  to  occur  after  long  intervals  of 
sterility. 

iv.  After  Term.  —  In  spite  of  all  the  risks  that  beset  the  life  of  a 
tubal  foetus  and  that  of  its  mother,  the  pregnancy  may  go  to  term. 
Then  a  remarkable  series  of  events  ensues. 

(a)  Paroxysmal  abdominal  pains  come  on,  resembling  those  of 
natural  labour,  accompanied  by  a  discharge  of  blood  and  mucus  from 
the  uterus  resembling  the  "  show,"  and  the  os  uteri  dilates. 

(6)  This  unavailing  labour  may  last  a  few  hours  or  days  (it  is 
stated  to  have  lasted  for  weeks  in  some  patients),  and  then  subside. 

(c)  The  mammae  may  continue  to  secrete  milk  for  several  weeks. 

These  signs  sometimes  pass  away,  the  amniotic  fluid  is  absorbed,  the 
swelling  diminishes  in  size,  and  the  retained  foetus  causes  no  trouble. 
In  the  majority  of  cases  suppuration  takes  place  in  the  sac,  the  foetus 
decomposes,  and  the  fragments  of  its  tissues  are  discharged  through 
sinuses  in  the  groin,  abdomen,  vagina,  rectum,  or  bladder.  It  should 
be  remembered  that  the  onset  of  labour  may  rupture  the  sac. 

In  extraperitoneal  rupture  —  that  is,  Avhen  the  tube  bursts  so  that  the 
blood  is  extravasated  between  the  layers  of  the  mesometrium — the 
symptoms  resemble  intraperitoneal  rupture,  but  as  a  rule  are  not  so 
severe,  and  the  signs  of  shock  pass  off  quicker.  On  examining  by  the 
vagina  a  rounded,  ill-defined  swelling  will  be  found  on  one  side  of  the 
uterus ;  when  the  effused  blood  is  large  in  amount  the  uterus  will  be 
pushed  to  the  opposite  side.  When  the  bleeding  takes  place  into  the 
left  mesometrium  it  will  sometimes  extend  backwards  under  the  peri- 
toneum, and  invade  the  connective  tissue  around  the  rectum ;  so  that 
when  the  exploring  finger  is  introduced  into  the  rectum,  a  semicircle, 
sometimes  a  ring,  of  swollen  tissue  will  be  felt  encircling  the  gut. 

The  escape  of  decidual  membrane  from  the  \iterus,  accompanied  by 
blood,  is  also  an  important  and  fairly  constant  sign.  Occasionally  it  will 
be  necessary  to  pass  a  sound  into  the  uterus ;  when  the  tube  is  gravid 
the  cavity  of  this  organ  will  be  found  slightly  enlarged,  and  the  os  is 


476  SYSTEM   OF  GYNECOLOGY 

invariably  patulous.  The  greatest  difficulty  in  these  cases  is  to  be  sure 
that  the  rupture  is  purely  extraperitoneal.  In  a  few  cases  the  rupture 
may  involve  the  peritoneal  as  well  as  the  niesometric  segment  of  the  tube. 

Not  infrequently  after  primary  extraperitoneal  rupture  the  symptoms 
of  shock  pass  off.  and  the  embryo  continues  its  development ;  in  many 
instances  in  which  the  patients  believe  themselves  pregnant,  the  haemor- 
rhages from  which  they  suffer,  and  the  signs  indicative  of  the  primary 
rupture,  may  cause  but  temporary  inconvenience.  As  the  embryo  grows 
the  abdomen  increases  in  size,  but  the  enlargement  differs  from  ordinary 
uterine  gestation  in  that  it  is  lateral  instead  of  median. 

The  Differential  Diagnosis  of  Tubal  Pregnancy.  —  The  diagnosis  of 
tubal  pregnancy  is  nearly  always  beset  with  anxiety,  which  becomes 
intensitied  when  complications  exist.     For  instance :  — 

i.  Uterine  and  tubal  pregnancy  are  sometimes  concurrent.  ii. 
Uterine  pregnancy  sometimes  follows  the  tubal  variety,  iii.  Tubal 
pregnancy  may  be  bilateral,  iv.  Tubal  pregnancy  may  be  repeated. 
V.    Tubal  pregnancy  and  ovarian  or  parovarian  tumours  may  co-exist. 

It  is  important  to  bear  in  mind  that  tubal  pregnancy  may  be  simu- 
lated by  a  variety  of  conditions  :  — 

(a)  Uterine  pregnancy.  (6)  Pregnancy  in  a  bicorned  uterus,  (c) 
Retroversion  of  a  gravid  uterus,  {d)  Spurious  pregnancy,  (e)  Ovarian 
tumours.  (/)  Uterine  tumours,  (g)  Mesometric  tumours,  (li)  Faeces 
in  the  rectum. 

Concurrent  Uterine  and  Tubal  Pregnancy.  —  Several  examples  of 
this  combination  have  been  recorded.  In  1881  Dr.  Galabin  described 
an  instance  of  it  in  a  woman  thirty-six  years  of  age. 

The  history  suggested  ovarian  cyst  complicated  with  pregnancy, 
and  that  the  cyst  had  ruptured.  A  combined  intra-uterine  and  extra- 
uterine gestation  was  regarded  as  possible.  Dr.  Galabin  performed 
abdominal  section.  On  opening  the  peritoneum  a  foetus  was  discov- 
ered enclosed  in  its  membrane  lying  to  the  right  side  of,  above,  and 
somewhat  behind  the  uterus.  The  placenta  appeared  to  be  spread  out 
very  widely,  and  attached  chiefly  to  the  posterior  surface  of  the  right 
broad  ligament  and  of  the  pregnant  uterus.  The  ])lacenta  was  not  dis- 
turbed. Two  days  later  labour  pains  came  on,  and  the  intra-uterine 
child  was  delivered;  it  was  dead.  The  patient  continued  to  lose  blood 
from  the  extra-uterine  sac,  and  died  three  days  after  the  operation.  No 
autopsy  was  allowed. 

Franklin  met  with  the  same  combination  in  a  woman,  mother  of  five 
children.  The  patient  was  in  labour  when  difficulty  was  experienced ; 
Caesarean  section  was  performed,  and  an  adventitious  mass  was  found 
in  the  pelvis :  this  was  found  to  be  an  extra-uterine  child.  Death  fol- 
lowed in  half  an  hour.  Similar  cases  have  been  reported  by  Cooke, 
Sale,  and  Wilson. 

Other  examples  have  l)een  reported,  but  these  illustrate  the  leading 
points  in  the  clinical  history  of  this  accident.  Its  gravity  is  sufficiently 
obvious,  for  in  all  the  reported  cases  the  patients  died  within  a  few  days 


EXTRA-UTERINE    GESTATION  ^y-j 

of  the  operation.  The  great  difficvalty  in  this,  as  in  all  other  examples 
of  advanced  extra-i;terine  gestation,  is  the  excessive  risk  of  haemorrhage 
which  follows  interference  with  the  placenta. 

Uterine  subsequent  to  Tubal  Gestation.  —  It  has  been  mentioned  that 
tubal  gestation  may  go  to  term,  spurious  labour  supervene,  and  the 
foetus  become  sequestrated  in  the  mesometriura  :  on  this  grave  accident 
uterine  pregnancy  may  supervene,  —  a  combination,  fortunately  for 
mothers,  very  rare. 

Stonham,  whilst  conducting  an  autopsy  on  a  woman  forty-three  years 
of  age,  ■who  died  in  the  seventh  month  of  her  pregnancy  from  bronchitis 
and  ulceration  of  the  trachea,  found  a  foetus  (enclosed  in  a  thick  membrane) 
in  the  right  mesometrium.  Some  of  the  bones  were  completely  macerated  ; 
the  soft  structures  were  soapy  in  consistence.  There  was  a  thin  deposit 
of  calcareous  material  on  the  inner  wall  of  the  cyst.  The  left  meso- 
metrium was  normal.  The  uterus  contained  a  seven  months'  foetus,  which 
was  apparently  living  at  the  mother's  death  since  it  showed  no  signs  of 
maceration.  Worrall  of  Sydney  published  details  of  a  case  in  which  a 
woman  with  a  foetus  in  the  mesometrium  subsequentl}"  conceived  in  the 
uterus.  The  nature  of  the  case  was  correctly  diagnosed,  and  an  opera- 
tion for  the  relief  of  the  condition  was  successfully  carried  out. 

The  patient  was  thirty  years  of  age,  and  mother  of  five  children. 
In  April  1888,  the  menses  having  been  absent  six  weeks,  she  was  seized 
in  the  night  with  severe  abdominal  pains,  faintness,  and  vomiting.  She 
was  confined  to  her  bed  six  weeks.  In  October  of  the  same  year,  at  about 
the  eighth  month  of  gestation,  a  sudden  flooding,  unaccompanied  by  pain, 
came  on,  and  lasted  three  days.  A  month  later  she  was  seized  with 
severe  abdominal  pains,  which  lasted  a  fortnight ;  she  then  began  to 
decrease  in  size,  and  menstruation  reappeared.  The  tumour  decreased 
to  a  certain  point,  and  then  remained  stationary.  After  July  1889  she 
ceased  to  menstruate,  and  her  abdomen  gradually  enlarged.  A  few  months 
later  Dr.  Worrall  was  consulted,  and  he  correctly  diagnosed  the  existence 
of  a  living  intra-uterine  foetus  and  an  extra-uterine  foetus  which  had  been 
dead  about  two  years.  Acting  on  this  diagnosis,  he  removed  the  extra- 
uterine foetus  from  the  left  mesometrium.  It  was  not  decomposed,  but 
was  very  flaccid,  and  weighed  4-i-  lbs.  The  placenta  was  left,  and  the 
sac  drained.  Next  day  labour  came  on,  and  the  intra-uterine  child  was 
born.  It  was  a  female,  and  cried  feebly,  "  but,  in  spite  of  every  care, 
died  in  a  few  hours."     The  patient  made  a  good  recoverj^ 

Bozeman  has  recorded  a  case  in  which  uterine  supervened  on  extra- 
uterine gestation.  After  delivery  of  the  intra-uterine  foetus  an  uneven 
and  projecting  mass  presented  in  the  recto-vaginal  fossa.  This  proved  to 
be  the  sac  of  an  extra-uterine  pregnancy.  From  the  history  of  the  case 
it  had  probably  been  dead  between  three  and  four  years.  The  contents 
of  the  sac  were  evacuated  through  the  vagina.     The  patient  recovered. 

Bilateral  (Concurrent)  Tubal  Pregnancy.  —  Several  suspected  exam- 
ples of  this  rare  condition  have  been  recorded,  but  in  many  the  evidence 
was  not  absolute.     In  1892  Dr.  W.  Walter  sent  me  two  Fallopian  tubes 


47S  SYSTEM   OF  GYNECOLOGY 

"whicli  lie  liad  removed  from  a  woman  twenty-nine  years  of  age.  The 
left  contained  an  embryo  and  placenta ;  the  Avails  of  the  gestation  sac 
had  burst  and  caused  severe  bleeding,  which  led  to  operation.  The 
right  tube  contained  a  typical  tubal  mole.  This,  so  far  as  I  know,  is 
the  first  indisputable  example  of  pregnancy  occurring  concurrently  in 
both  Fallopian  tubes  of  the  same  individual. 

Repeated  Tubal  Pregnancy.  —  Under  this  heading  it  is  usual  to  place 
those- cases,  fortunately  rare,  in  which  Avomen  have  conceived  in  one 
tube  and  have  been  submitted  to  operation  ;  and  that  subsequently  the 
remaining  tube  became  gravid. 

Dr.  Herman  has  recorded  an  example  of  this  condition.  In  January 
1887,  he  removed  from  a  Avoman  tAventy-eight  years  of  age  a  gravid  right 
Fallopian  tube  which  had  burst  into  the  peritoneal  cavity.  In  May  1890 
the  patient  again  came  under  observation  for  pelvic  trouble,  and  Herman 
came  to  the  conclusion  that  the  Avoman  was  again  the  victim  of  tubal 
pregnancy.  Abdominal  section  was  performed  and  the  left  Fallopian 
tube  Avas  removed.     It  contained  a  tubal  mole. 

Mr.  LaAvson  Tait,  in  1885,  operated  on  a  Avoman  twenty-five  years  of 
age,  and  removed  a  gestation  sac  with  the  foetus  and  placenta  from  the 
right  side  of  the  pelvis.  This  woman  recovered,  and  eighteen  months 
later  was  confined  of  a  child  at  term.  Fifteen  months  after  delivery 
she  again  became  pregnant,  and  when,  according  to  her  computation, 
the  pregnancy  had  advanced  to  the  fourth  month  she  was  seized  Avitli 
a  severe  abdominal  pain  and  died  in  five  hours.  At  the  autopsy  a  tubo- 
uterine  gestation  was  found  on  the  left  side. 

Mackenrodt  reported  the  case  of  a  woman  thirty-tAvo  years  of  age 
who  was  seized  in  May  1890  with  signs  indicating  rupture  of  a  gravid 
tube.  These  signs  were  repeated  in  October  1891.  The  abdomen  was 
opened,  and  a  gestation  sac  the  size  of  a  large  egg  removed  from  the  left 
side.  On  the  opposite  side  a  second  sac  was  found  containing  foetal  bones. 

Twin  Tahal  Pregnancy.  —  A  few  Avr iters  on  extra-uterine  pregnancy, 
Parry  especially,  deal  with  the  subject  of  twins  in  tubal  pregnancy  as 
if  it  Avere  a  common  event.  A  critical  study  of  Tarry's  writings  shows 
clearly  enough  that  he  confounded  three  distinct  conditions  :  — 

i.  Concurrent  tubal  and  uterine  gestation,  ii.  Uterine  subsequent 
to  tubal  pregnancy,     iii.  Twin  gestation  in  a  Fallopian  tube. 

An  example  of  tubal  twins  has  yet  to  be  recorded. 

Tubal  Pregnancy  an/l  Ovarian  Tamours  sometimes  co-exist.  —  Several 
instances  have  been  recorded  in  which  ovarian  or  parovarian  cysts  have 
co-existed  with  a  gravid  tube.  In  some  cases  a  parovarian  cyst  has 
existed  on  the  same  side  as  the  pregnant  tube,  and  may  perhaps  have 
determined  the  accident.  In  a  case  under  my  own  care  an  ovarian  cyst 
as  large  as  a  cocoa-nut  existed  on  the  right  side  and  a  gravid  tube  (which 
had  aborted)  on  the  left. 

It  is  rarely  that  an  ovarian  tumour  co-existing  Avith  uterine  pregnancy 
simulates  combined  tubal  and  uterine  j)regnancy.  In  1891  Dr.  Gi-i'fiith 
communicated  to  the  Obstetrical  Society  details  of  a  case  in  which  a 


EXTRA-UTERINE    GESTATION  479 

woman  in  labour  came  under  his  care.  She  was  supposed  to  have  twins, 
one  intra-uterine  and  the  other  extra-uterine.  It  ultimately  turned  out 
that  the  patient  was  pregnant,  and  what  was  supposed  to  be  the  head 
of  an  extra-uterine  child  was  a  large  fibroma  of  the  ovary  obstructing 
labour.  She  died,  and  the  pelvis  Avith  the  organ  and  tumour  in  position 
was  bisected ;  one-half  of  the  specimen  is  preserved  in  the  museum  of 
the  Eoyal  College  of  Surgeons,  the  other  in  that  of  St.  Bartholomew's 
Hospital,  London. 

Normal  Pregnancy.  —  This  has  been  mistaken  for  tubal  pregnancy. 
The  abdomen  has  been  opened,  the  fcetus  extracted,  and  the  uterus 
amputated  before  the  error  was  discovered. 

Pregnancy  in  one  Horn  of  a  Bicorned  Uterus.  — A  few  cases  are  known 
in  which  this  anomaly  has  led  to  grave  difficulty  in  diagnosis  and  to  error 
in  treatment.  Pregnancy  in  the  ill-developed  horn  of  the  so-called 
"unicorn"  uterus  requires  the  same  treatment  as  tubal  pregnancy. 

Abnormal  Thinness  of  the  Walls  of  a  Gravid  Uterus.  —  Lawson  Tait 
has  drawn  attention  to  some  cases  which  have  fallen  under  his  notice 
in  which  the  walls  of  the  uterus  were  of  such  extreme  thinness  that  the 
fcetus  could  be  easily  felt.  And  in  reference  to  one  case  he  writes, 
"  The  child  could  be  felt  with  the  most  astonishing  distinctness,  and  it 
floated  about  as  if  it  were  perfectly  free  in  the  abdomen."  There  is 
also  a  reference  to  a  similar  condition  in  Parry's  well-known  work. 
That  this  is  a  condition  to  bear  in  mind  the  following  case,  furnished 
me  by  a  surgeon,  well  illustrates  :  — 

A  woman,  twenty-nine  years  of  age,  was  admitted  into  the  infirmaiy  in 
such  an  antemic  and  emaciated  condition  that  she  was  too  weak  to  stand. 
There  was  vomiting,  amenorrhoea  of  six  months'  standing,  pigmentation 
along  the  linea  alba,  and  milk  in  the  breasts.  The  belly  was  distended, 
and  in  the  right  iliac  fossa  was  lodged  a  crescentic  mass  not  unlike  a 
foetus  in  outline,  and  so  mobile  that  it  could  be  pushed  into  the  riglit 
iliac  fossa.  The  remarkable  ease  with  which  this  body  could  be  grasped, 
and  its  position  when  at  rest,  led  to  the  diagnosis  of  extra-uterine  i)reg- 
nancy,  and  an  operation  decided  upon.  On  incising  the  peritoneum  a 
smooth  glistening  body  of  a  pearly  gray  colour,  exactly  like  an  ovarian 
cyst,  was  seen,  but  it  had  the  shape  and  occupied  the  position  of  the 
uterus.  The  foetus  could  be  felt  and  pushed  about  in  the  fluid  Avitli 
ease.  The  wound  was  at  once  closed.  INIiscarriage  took  place  on  the 
third  day.     The  woman  recovered. 

In  such  cases,  when  the  diagnosis  is  so  doubtful,  before  resorting  to 
operation  the  employment  of  a  uterine  sound  would  easily  determine 
the  nature  of  the  case. 

Retroversion  of  the  gravid  uterus  has  been  a  source  of  error.  Eeten- 
sion  of  urine,  so  characteristic  of  this  condition,  is  occasionally  produced 
when  the  embryo  occupies  the  mesometrium,  accompanied  by  much 
hemorrhage.  On  the  other  hand  extra-uterine  gestation  has  been  mis- 
taken for  retroversion  of  a  gravid  uterus.  Pr.  Godson  relates  a  case 
which  occurred  in  a  woman  who  had  been  married  thirteen  years.     A 


4So  SYSTEM   OF  GYNECOLOGY 

year  after  marriage  she  had  one  child.  She  remained  sterile  for  twelve 
years,  and  then  became  pregnant.  On  account  of  inability  to  pass  water 
she  was  admitted  into  St.  Bartholomew's  Hospital,  and  an  ineffectual 
attempt  made  to  replace  the  uterus.  Eventually  Dr.  Carter  removed 
an  extra-uterine  foetus  by  abdominal  section. 

Spurious  Pregnancy.  —  It  is  well  known  that  in  several  instances  the 
abdomen  has  been  opened  under  the  impression  that  the  patients  were 
suffering  from  tubal  pregnancy,  but  nothing  abnormal  found. 

Dr.  Sinclair  Stevenson  reported  a  case  of  spurious  pregnancy  simulat- 
ing ectopic  gestation  of  the  fourth  month  in  which  there  was  amenorrhoea. 
So  strongly  marked  were  the  signs  of  tubal  pregnancy  that  the  abdomen 
was  opened ;  instead  of  pregnancy  a  small  cyst  of  the  ovary  was  found. 

Lastly,  the  difficulties  which  sometimes  beset  the  differential  diagnosis 
of  pelvic  swellings  is  shown  by  the  fact  that  in  very  many  instances 
abdominal  section  has  been  undertaken  to  remove  supposed  ovarian 
tumours,  dilated  tubes,  and  the  like,  which  turned  out  to  be  gestation 
sacs.  This  is  no  reflection  on  the  surgeon,  and  the  interference  is  more 
than  justified. 

Mr.  Skene  Keith  has  briefly  mentioned  a  case  in  which  his  father 
performed  abdominal  section,  expecting  to  find  a  "  fibroid  tumour " ; 
but  on  cutting  into  it,  a  foetus  was  found  which  had  been  dead  nearly 
two  years. 

Mr.  Knowsley  Thornton  and  others  have  dissected  out  gestation 
sacs  under  the  belief  that  they  were  dealing  with  tumours. 

On  the  other  hand,  operations  have  been  undertaken  under  the 
impression  that  the  patients  were  victims  to  advanced  extra-uterine 
pregnancy ;  but  tumours  and  even  a  mass  of  faeces  in  the  rectum  have 
been  found  instead. 

Sir  John  Williams  writes :  "  I  once  saw  a  swelling,  which  appeared 
to  Vje  a  small  ovarian  cyst,  aspirated.  It  proved  afterwards  to  be  the 
placenta  in  a  case  of  extraruterine  gestation." 

One  of  the  gravest  errors  is  to  mistake  a  tubal  pregnancy  in  its 
mesometric  stage  for  a  sarcoma  or  myoma  when  the  parts  have  been 
exposed  by  abdominal  section.  This  is  a  serious  error,  as  the  operator, 
instead  of  opening  the  sac,  attempts  to  remove  the  tumour,  usually  with 
a  fatal  result. 

The  Treatment  of  Tubal  Gestation. — The  admirable  results  which 
liave  followed  the  treatment  of  tubal  pregnancy  by  abdominal  section 
have  served  to  establish  this  method  on  as  secure  a  footing  as  ovariotomy. 

Methods  formerly  advocated,  such  as  killing  the  foetus  by  injecting 
drugs  into  its  body,  or,  more  recently,  by  electricity  and  similar  un- 
surgical  procedures,  are  of  such  an  unsatisfactory  character  that  they 
will  not  be  considered. 

The  risks  and  difficulties  of  an  operation  for  tubal  pregnancy  depend 
mainly  upon  the  extent  to  which  gestation  has  advanced  at  the  time  the 
operation  is  jicrfoi-nKid.  The  operative  treatment  may  be  considered 
in  the  following  stages:  — 


EXTRA-UTERINE   GESTATION  481 

i.  Before  primary  rupture  or  abortion,  ii.  At  the  time  of  primary 
rupture,  iii.  Subsequent  to  rupture,  iv.  When  the  embryo  and  placenta 
occupy  the  mesometrium.  The  fourth  stage  must  be  considered  in  sec- 
tions, thus :  (a)  At  or  near  term,  the  child  being  alive,  (if)  At,  near,  or 
after  term,  the  child  being  dead,  mummified,  or  reduced  to  a  Uthopcedion. 
(c)  After  decomposition  of  the  foetus  and  suppuration  in  the  sac. 

i.  Before  Primary  liuptare  or  Abortion.  —  Opportunities  of  dealing 
with  cases  in  this  stage  are  uncommon,  as  gravid  tubes  rarely  cause 
trouble  before  they  rupture  or  abort.  When  the  evidence  is  convincing, 
cceliotomy  should  be  performed  without  delay. 

ii.  At  the  Time  of  Primary  Rupture  or  Abortion.  —  The  majority  of 
cases  of  tubal  pregnancy  come  under  observation  at  the  time  of  primary 
rupture  or  abortion,  and  this  is  usually  some  period  between  the  fourth 
and  twelfth  week. 

When  the  symptoms  of  haemorrhage  are  unmistakable  and  the 
patient's  life  in  grave  danger,  cceliotomy  should  be  performed  without 
delay,  unless  there  be  good  evidence  that  the  rupture  is  extraperitoneal. 
The  employment  of  this  method  is  in  strict  accordance  with  the  canon 
of  surgery,  valid  in  other  regions  of  the  body,  namely,  to  arrest  haemor- 
rhage at  the  earliest  possible  moment. 

There  are  few  accidents  that  test  the  skill,  nerve,  and  resource  of  a 
surgeon  more  than  cceliotomy  for  a  suspected  intraperitoneal  rupture  of 
a  gravid  tube,  and  few  operations  are  followed  by  such  brilliant  results. 

The  method  of  performing  the  operation  before  and  at  the  time  of 
primary  rupture  is  identical  with  oophorectomy. 

Occasionally  the  rent  in  the  tube  may  extend  to  the  fundus  of  the 
uterus,  especially  if  the  embryo  be  lodged  near  the  uterus.  Such  rents 
should  be  carefully  sutured  with  cat-gut ;  occasionally  it  will  be  necessary 
to  use  silk  to  control  the  bleeding. 

iii.  After  Primary  Rupture.  —  Cases  are  submitted  to  operation  at 
periods  varying  from  a  few  days  to  weeks  or  even  months  after  the  tube 
has  ruptured.  It  has  been  already  pointed  out  that  in  an  exceedingly 
large  proportion  of  these  cases  the  tube  is  occupied  by  a  mole. 

AVhen  the  tube  bursts  the  haemorrhage  may  not  be  so  profuse  as  to 
induce  death,  and  the  patient,  recovering  from  the  shock,  may  not  mani- 
fest such  grave  symptoms  as  to  make  surgical  aid  obviously  necessary. 
The  consequence  is  that  the  patient  remains  for  several  weeks  under 
palliative  treatment  (unless  a  renewal  of  bleeding  killed  her).  At  last 
surgical  aid  is  sought,  and  a  discovery  of  the  true  nature  of  the  ease 
leads  to  cceliotomy. 

In  such  cases,  when  the  abdomen  is  opened,  the  free  blood  is  easily 
washed  out  by  a  stream  of  warm  water.  The  damaged  tube  and  ovary 
are  removed  as  in  oophorectomy.  When  much  free  bh^od  exists  in  the 
peritoneal  cavity  care  must  be  taken  that  no  clots  are  aHowed  to  remain 
in  the  iliac  fossae.  When  blood  has  remained  in  the  peritoneal  cavity 
for  several  weeks  after  rupture  it  is  invariably  necessary  to  drain. 

The  cases  in  which  abortion  or  rupture  of  gravid  tubes  gives  rise  to 

2i 


482  SYSTEM  OF  GYNECOLOGY 

iutraperitoneal  bleeding  moderate  in  amount,  and  insufficient  to  give  rise 
to  symptoms  wliich  directly  threaten  life,  are  those  in  which  the  effused 
blood  eventually  becomes  shut  off  from  the  general  peritoneal  cavity  by 
adhesions  of  intestines  and  omentum,  as  explained  in  the  section  dealing 
with  primary  intraperitoneal  rupture  (p.  462). 

Experience  has  not  yet  decided  whether  it  is  safer  for  the  patient 
under  such  conditions  to  run  the  risks  of  immediate  operation  or  to  wait 
for  a  few  weeks  in  order  to  ascertain  if  absorption  will  occur.  At  pres- 
ent I  believe  the  patient's  interests  are  best  served  by  allowing  her  to 
recover  from  the  immediate  shock,  and  then  dealing  with  the  damaged 
tube  by  coeliotomy. 

iv.  MesometriG  Gestation.  —  When  the  tube  bursts  between  the  layers 
of  the  mesometrium  operative  interference  is  rarely  called  for.  In  a  small 
proportion  of  cases  the  embryo  survives  the  accident  and  continues  to 
grow ;  and  at  any  date  from  this  period,  up  to  term,  surgical  interference 
may  be  called  for  to  save  the  patient  from  the  disastrous  effects  of  sec- 
imdary  rupture  into  the  coelom. 

When  gestation  has  not  advanced  beyond  the  fourth  month,  it  is 
possible  to  remove  the  embryo,  tube,  ovary,  and  adjacent  portion  of  the 
mesometrium  with  the  placenta,  and  thoroughly  to  remove  all  blood-clot. 

^Vhen  gestation  has  advanced  beyond  the  fourth  month  the  placenta 
has  become  too  large  to  be  dealt  with  in  this  summary  manner ;  at  the 
same  time,  the  sac  has  encroached  upon  the  peritoneum  belonging  to 
adjacent  organs,  such  as  the  uterus  and  rectum,  the  bladder,  and  not 
infrequently  the  anterior  wall  of  the  abdomen. 

After  the  fifth  month  operative  measures  for  tubal  gestation  must 
be  considered  under  two  headings :  —  (a)  The  treatment  of  the  sac ;  (&) 
The  treatment  of  the  placenta. 

(a)  The  Treatment  of  the  Sac.  —  The  gestation  sac  in  the  last  stages 
of  tubal  jjregnancy  consists  of  the  remnants  of  the  expanded  tube  and 
the  mesometrium,  which  may  be  thickened  in  some  parts  and  expanded 
in  others.  Coils  of  intestine  and  omentum  usually  adhere  to  the  walls 
of  the  sac.  The  removal  of  such  a  sac  is  fraught  with  considerable  risk, 
not  only  to  the  adjacent  large  blood-vessels,  but  to  the  viscera  and  ureters. 
Nevertheless,  in  spite  of  the  great  risk  of  the  proceeding,  it  has  on  one 
occasion  been  successfully  accomplished,  and  the  patient  luckily  recovered. 
It  will  generally  be  found  that  in  cases  where  attempts  have  been  made 
to  dissect  out  the  sac,  the  operation  was  begun  under  the  impression 
that  the  abnormal  mass  was  a  tumour. 

Experience  has  decided  clearly  enough  that  the  safest  plan  is  to  incise 
the  sac,  remove  the  fcjetus,  and  stitch  the  edges  of  the  sac  to  the  abdom- 
inal wound;  precisely  as  in  the  plan  recommended  after  enucleating 
large  cysts  and  tumours  from  between  the  layers  of  the  mesometrium. 

In  those  cases  wlifjre  the  gestation  has  wciU  advanced,  the  ])oritoneum 
may  be  so  removed  from  tin;  anterior  abdominal  wall  that  the  sac  can 
be  penetrated  without  iutenti(jnally  opening  the  peritoneal  cavity  at  any 
stage  of  the  operation. 


EXTRA-UTERINE    GESTATION  483 

(&)  The  chief  difficulty  which  perplexes  the  operator  is  how  to  deal  with 
the  placenta.  There  can  be  no  doubt  that  the  situation  of  the  placenta 
largely  influences  the  result,  and  so  far  as  I  can  judge  from  the  reports  of 
cases,  as  well  as  from  my  own  experience,  the  most  promising  cases  are 
those  in  which  the  placenta  is  situated  in  the  pelvis  below  the  foetus. 
When  the  placenta  is  situated  above  the  foetus  it  will,  in  many  cases,  be 
incised  as  the  sac  is  opened,  and  give  rise  to  such  furious  bleeding  that 
in  several  cases  the  patient  has  succumbed  to  the  hcEmorrhage.  Even 
prompt  seizure  and  ligature  of  the  pedicle  on  the  uterine  side  of  the  sac 
fail  to  arrest  the  bleeding ;  in  such  a  case  the  abdominal  aorta  must  be 
compressed;  and  such  methods  as  packing  with  sponges  and  the  applica- 
tion of  perchloride  or  persulphate  of  iron  to  the  bleeding  surfaces  have 
been  adopted,  in  a  few  instances  with  success. 

The  fear  of  such  haemorrhage  and  its  uncontrollable  character  have 
induced  several  surgeons  to  adopt  the  alternative  plan  of  leaving  the 
placenta,  and  allowing  it  to  slough  aAvay  gradually,  taking  care,  of  course, 
to  keep  up  a  free  communication  with  the  exterior.  The  disadvantages  of 
this  method  are  many.  The  process  of  suppuration  and  discharge  of  the 
placenta  is  long  and  dangerous  on  account  of  the  great  risk  the  patient 
runs  of  septicaemia  and  peritonitis  ;  in  a  large  proportion  of  cases  a  faecal 
fistula  forms;  in  the  majority  of  cases,  however,  such  fistulas  gradually 
close  as  the  patient  convalesces. 

In  order  to  avoid  this  risk  attempts  have  been  made,  after  removing 
the  foetus,  to  irrigate  the  gestation  sac,  and  to  tie  the  cord  thoroughly  close 
to  the  placenta  without  disturbing  the  latter ;  the  cavity  must  be 
cautiously  sponged  and  then  hermetically  closed,  in  the  hope  that  the 
'placenta  will  atrophy.  Unfortunately  for  this  method  there  is  another 
source  of  infection  to  reckon  with.  It  has  already  been  mentioned  that, 
as  the  gestation  sac  enlarges,  it  frequently  strips  the  peritoneum  from  the 
rectum,  and  thus  the  placenta  itself  may  acquire  adhesions  to  the  bowels. 
The  result  is  that  intestinal  micro-organisms  gain  access  to  the  placenta 
and  set  up  decomposition. 

With  our  present  experience  the  rules  for  the  treatment  of  the 
placenta  may  be  formulated  thus :  —  i.  When  the  placenta  is  situated 
above  the  foetus  it  is  good  practice  to  attempt  its  removal,  ii.  In 
some  instances  the  placenta  becomes  detached  in  the  course  of  the  opera- 
tion, and  leaves  no  choice,  iii.  AVhen  the  placenta  is  below  the  foetus  it 
may  be  left.  iv.  Should  the  placenta  be  left,  and  the  sac  closed,  and  there- 
after symptoms  of  sui)puration  occur,  then  the  wound  must  be  reopened 
and  the  placenta  removed,  v.  If  the  foetus  die  before  the  operation  is 
attempted  tlie  placenta  can  be  removed  without  risk  of  haemorrhage. 

Could  Ave  feel  sure  that  the  placenta  would  not  decompose,  the  best 
method  would  be  to  close  the  sac  hermetically,  and  leave  the  placenta  to 
atrophy ;  or  to  wait  until  we  know  that  the  placental  circulation  had  ceased, 
then  reopen  the  sac  and  take  out  the  placenta.  Unfortunately,  we  have 
no  precise  data  to  guide  us  in  this  respect,  and  whilst  waiting  for  the 
placenta  to  die,  its  tissues  decompose. 


484  SYSTEM  OF  GYNAECOLOGY 


Apprehension  that  the  placenta  may  grow  after  the  foetus  has  been 
removed,  is  absolutely  groimdless  ;  there  is  positive  evidence  that,  if  it 
does  not  decompose,  it  quietly  and  completely  atrophies.  This  is  further 
proved  by  the  absence  of  placenta,  when  the  foetus  is  in  the  state  of 
lithopa?dion. 

The  great  risk  of  violent  hsemorrhage  renders  an  operation  for  tubal 
pregnancy  with  a  quick  placenta  between  the  fifth  and  ninth  months  of 
gestation  the  most  dangerous  in  the  whole  range  of  surgery ;  hence  it 
cannot  be  urged  with  too  much  force  that  as  soon  as  it  is  fairly  evident 
that  a  woman  has  a  tubal  pregnancy,  it  should  be  dealt  ivith  by  operation 
ivithout  delay. 

It  has  been  urged  that  if,  after  primary  rupture,  there  is  evidence 
that  the  child  is  developing,  operative  interference  should  be  deferred 
until  the  seventh  month,  unless  urgent  symptoms  arise,  as  there  may  be 
a  prospect  of  saving  the  child's  life.  To  my  mind  this  is  an  objection- 
able practice,  for  the  following  reasons  :  —  i.  Extra-uterine  children  are 
puny,  ill-developed  and,  in  a  large  proportion  of  cases,  malformed,  ii. 
They  rarely  survive  extraction  many  weeks,  or  many  months  at  most, 
iii.  In  endeavouring  to  save  the  life  of  a  defective  child  the  more  valuable 
life  of  the  mother  is  frequently  sacrificed.  It  is,  of  course,  conceivable 
that  in  some  cases  the  life  of  the  child  may  be  of  great  importance. 

After  Death  of  the  Foetus  at  or  near  Term.  —  Operations  after  the  death 
of  the  foetus  are  less  complicated  than  when  it  is  alive  and  the  placental 
circulation  in  full  vigour.  Not  only  is  the  proceeding  simplified  from  the 
operative  point  of  view,  but  the  results,  in  so  far  as  the  mother  is  con- 
cerned, are  also  much  more  satisfactory. 

When  the  operation  is  undertaken  in  cases  where  the  foetus  is  in  the 
state  of  lithopmdion  the  procedure  is  very  simple,  because  the  placenta  has 
completely  disappeared.  There  is  a  circumstance  in  connection  with  a 
foetus  wholly  or  partially  converted  into  adij)ocere  which  is  of  some  impor- 
tance to  the  surgeon,  namely,  that  its  tissues  have  a  strong  tendency  to 
adhere  to  the  walls  of  the  sac. 

After  Decomposition  of  the  Foetus  and  Suppuration  of  the  Sac.  —  After 
death  and  decomposition  of  the  ffstus  fistulas  form,  by  which  pus,  accom- 
panied by  fragments  of  foetal  tissue  and  bones,  finds  an  exit  —  either 
through  the  rectum,  vagina,  bladder,  uterus,  or  at  some  spot  in  the  anterior 
abdominal  wall  below  the  umbilicus.  The  treatment  in  such  cases  is  sim- 
plicity itself.  The  sinuses  should  be  dilated,  and  all  fragments  removed 
from  the  cavity  in  which  they  lie.  When  this  is  done  thoroughly,  the  si- 
nuses will  rapidly  granulate  and  close.  Partial  operations  are  useless;  if 
but  a  bit  of  a  bone  }je  allowed  to  remain,  a  troublesome  fistula  will  persist. 

John  Bland  Sutton. 

The  works  of  ^catost  value  on  the  subject  of  extra-uterine  gestation  in  the  English 
language  are  the  following:  — 

(JAMPiiKLL,  WiLMAM.  Memoir  on  Extra-Uterine  Gestation.  Edinburgh,  1840. 
This  brochure   is  useful,   as  it  reveals  the  slender  and  unreliable  character  of  the 


PELVIC  INFLAMMATION  485 

evidence  on  which  the  varieties  of  extra-uterine  gestation  were  based  in  the  early 
part  of  this  century. 

Parry,  John  S.  Extra-Uterine  Pregnancy :  its  Causes,  Species,  Patholof/icul 
Anatomy,  Clinical  History,  Diagnosis,  Prognosis,  and  Treatment.  London,  1870. 
This  work  is  a  great  improvement  on  that  of  Campbell  ;  but  like  that  book,  its  great 
defect  is  the  admission,  uncriticised,  of  every  rei^orted  case  as  evidence  of  the  existence 
of  the  speculative  varieties  of  extra-uterine  gestation  according  to  the  fancy  of  the 
reporter. 

Tait,  Lawson.  Ectopic  Gestation,  1888.  This  epoch-making  brochure  is  valuable 
only  for  the  great  advance  it  marks  in  the  surgery  of  tubal  gestation,  but  for  the 
admirable  generalisation  enunciated  by  its  author  that  pjrohahly  all  forms  of  ectopic 
pregnancy  have  their  starting-point  in  the  Fallopian  tubes.  This  generalisation,  sub- 
sequently put  on  an  anatomical  basis  by  other  workers,  has  served  more  than  any- 
thing else  to  revolutionise  the  pathology  and  surgery  of  what  was  formerly  termed 
"  pelvic  hsematocele." 

REFERENCES 

1.  Barnes.  Trans.  Obstet.  Soc.  vol.  xxiii.  p.  170.  —  2.  Berry  Hart  and  Carter, 
note  Edinburgh  Medical  Journal,  vol.  xxxiii.  322.  —  3.  Bozeman.  New  l'o?•^•  Med. 
Journal,  1884,  vol.  xl.  p.  ()'J3. — 4.  Champneys.  Trans.  Obstet.  Soc.  vol.  xix.  p. 
456. — 5.  Cheston.  Medico-Chir.  Trans.  xo\.  v.  p.  104.  —  (>.  Dezeimeris.  Journal 
ds  Coymaissances,  Medico-Chirurgicales,  1836.  Reprinted  and  translated  by  Berry 
Hart  in  Obstet.  Trans.  Edin.  vol.  xviii.  p.  233,  and  Am.  Jour,  of  Obstetrics,  vol.  xxix. 
p.  577.-7.  Franklin.  Brit.  Med.  Journal,  1894,  vol.  i.  p.  1019. — 8.  Galabin. 
Trans.  Obstet.  Soc.  vol.  xiii.  p.  821.  —  9.  Godson.  Proc.  Med.  Soc.  London,  vol.  vii.  p. 
390. —  10.  Herman.  Brit.  Med.  Journal,  1890,  vol.  ii.  p.  722.  — 11.  Jessop.  Trans. 
Obstet.  Soc.  vol.  xviii.  p.  261.  — 12.  Keith,  Skene.  Obstet.  Trans.  Edin.  vol.  x.  p.  92.  — 
13.  Malherbe.  Bull.de  la  Soc.  Anat.de  Paris,  t.ix.  p.  o. — 14.  Stevenson.  Sinclair. 
Trails.  Obstet.  Sue.  yo\.  xxxii.  p.  2H). — 15.  Stonham.  Trans.  Path.  Soc.  vol.  xxxviii. 
p.  445.  — 16.  Taylor.  Trans.  Obstet.  Soc.  vol.  xxxiii.  p.  115. —  17.  Tilt.  Trans. 
Obstet.  Soc.  1873,  vol.  xv.  p.  155.  — 18.  Worrall.  Med.  Press  and  Circular,  1891,  vol. 
i.  p.  296. —19.  Walter.  B7-it.  Med.  Journal,  1892,  vol.  ii.  p.  732.-20.  Webster, 
Clarence.  Ectopic  Pregnancy,  1895.  —  21.  Williams,  Sir  John.  Trans.  Obstet.  Soc. 
vol.  xxix.  p.  490. 

J.  B.  S. 


PELVIC   INFLAMMATION 

In  dealing  with  so  wide  a  subject  as  pelvic  inflammation  it  is  necessary 
at  the  outset  to  state  the  precise  meaning  which,  so  far  as  the  present 
article  is  concerned,  those  words  are  intended  to  convey.  The  phrase, 
as  here  used,  must  be  understood  to  include  the  two  affections  known 
as  pelvic  cellulitis  and  pelvic  peritonitis.  The  inflammation  of  the  several 
viscera  contained  in  the  female  pelvis  will  be  described  in  other  parts 
of  this  work,  and  will  only  be  referred  to  here  in  so  far  as  they  are 
concerned  in  the  pathological  processes  that  lead  to  the  two  diseases 
just  named. 

Several  writers  of  distinction,  amongst  whom  Yirchow  and  INIatthews 
Duncan  may  be  specially  mentioned,  have  named  the  inflammations  noAv 
about  to  be  considered  '•  perimetritis  "  and  "''parametritis  "  :  the  former 
name  was  used  by  them  to  signify  inflammation  of  the  pelvic  peritoneum ; 


4S6  SYSTEM  OF  GYNECOLOGY 

the  latter  to  signify  inflammation  of  the  pelvic  connective  tissue.  These 
terms,  have  not  been  adopted  in  the  following  article,  for  several  reasons 
of  "which  onl}^  two  or  three  need  be  given.  Firstly,  the  Avorcls  perime- 
tritis and  parametritis  are  so  nearly  alike  that  their  use  may  introduce 
an  additional  and  quite  unnecessary  element  of  confusion  into  a  subject 
that,  for  the  beginner  at  any  rate,  is  already  sufficiently  beset  Avitli  dif- 
ficulties :  secondly,  these  terms  imply  a  difference  in  the  anatomical 
relations  of  the  peritoneum  and  of  the  connective  tissue  to  the  uterus 
which  does  not  really  exist ;  the  pelvic  connective  tissue  and  pelvic 
peritoneum  are  in  equally  close  contact  with  the  uterus.  It  is  inaccurate 
and  misleading,  therefore,  to  speak  of  an  inflammation  of  the  one  tissvie 
as  being  an  inflammation  around  the  uterus,  and  an  inflammation  of  the 
other  as  being  an  inflammation  near  it.  Thirdly,  the  words  perimetritis 
and  parametritis  describe,  in  terms  of  the  uterus  alone,  affections  which 
often  involve  all  parts  of  the  pelvis,  and  are  not  necessarily  uterine  even 
in  their  origin. 

Until  recent  years  the  views  generally  held  and  taught  with  reference 
to  pelvic  inflammation  were  exceedingly  vague  and  unsatisfactory;  in  many 
respects  indeed  erroneous.  Clinical  observation  was  so  seldom  brought 
to  the  test  of  the  operating  theatre  and  the  post-mortem  room  that  certain 
erroneous  inferences  drawn  from  facts  observed  at  the  bedside  remained 
year  after  year  uncorrected  by  actual  inspection  and  dissection,  and  were 
thus  accepted  as  articles  of  current  professional  belief.  Almost  every 
attack  of  pelvic  inflammation  was  believed  to  be  a  cellulitis ;  and  if,  on 
vaginal  examination,  a  hard,  irregular,  fixed  mass  could  be  felt  on  one 
or  both  sides  of  the  uterus,  the  diagnosis  of  cellulitis  was  held  to  be 
established  beyond  cavil.  It  is  true  that  many  years  ago  Aran  and 
Bernutz,  in  France,  combated  this  view,  and  the  latter  proved  by  a 
large  mass  of  post-mortem  evidence  the  true  nature  of  the  majority  of 
these  swellings :  but  the  influence  of  their  writings  upon  the  current 
belief  and  teaching  was  for  many  years  inappreciable.  It  was  not, 
indeed,  until  the  practice  of  abdominal  surgery  became  extended,  and 
opportunities  of  comparing  the  physical  signs  with  the  actual  conditions 
became  thereby  more  frequent,  that  the  truth  of  their  main  contention 
began  to  be  generally  recognised  and  accepted.  The  knowledge  thus 
gained  from  a])dominal  surgery  on  the  one  hand,  and  the  advances  made 
in  our  knowledge  of  the  anatomy  of  the  female  pelvis  —  especially  by 
the  study  of  frozen  s(!ctions  —  on  the  other,  have  comjjletely  revolu- 
tionised our  views  of  pelvic  inflammation;  and  the  light  shed  by  modern 
research  on  the  inflammatory  process  itself  has  tended  still  further  in  the 
same  direction.  Whosoever  now  undertakes  to  give  an  account  of  pelvic 
inflammation  must  consider  it  from  an  entirely  new  stand-point,  both  as 
regards  its  etiology,  its  jjatliology,  its  diagnosis,  and  its  treatment.  It 
is  not  pretended  that  oui'  knowledge  is  as  yet  sufficiently  complete  to 
make  it  possil^le  to  deal  with  any  of  these  points  in  an  entirely  satisfactory 
manner.  All  we  can  attempt  at  present  is  to  indicate  tlui  lines  on  which 
the  subject  must  be  studied  henceforth, and  to  eliminate  from  the  descrip- 


PELVIC  INFLAMMATION  487 

tion   all  that  modern  investigation   lias    sliown   to   be   ill-founded   or 
erroneous. 

After  these  introductory  remarks  on  the  general  subject  of  pelvic 
inflammation,  we  may  proceed  to  consider  its  two  great  varieties. 

Pelvic  Cellulitis 
(Synonyms.  —  Parametritis  ;  Periuterine  'phlegmon) 

Definition. — Pelvic  cellulitis  is  an  inflammation  of  the  pelvic  connec- 
tive tissue.  Such  an  inflammation  may  be  primary  or  secondary;  that  is, 
it  may  originate  in  the  connective  tissue  itself,  or  it  may  originate  in  one 
of  the  neighbouring  structures  and  reach  the  connective  tissue  by  exten- 
sion. The  primary  form,  which  is  the  one  here  considered,  is  an  acute 
infective  disease ;  indeed,  it  dift'ers  in  no  respect  from  acute  inflammation 
of  the  connective  tissue  in  any  other  part  of  the  body.  Chronic  pelvic 
cellulitis  is  always  a  secondary  affection,  complicating  inflammation  of 
some  other  part ;  it  is  never  the  sequel  of  an  acute  cellulitis. 

Anatomy.  —  The  pelvic  connective  tissue  is  not  a  special  structure, 
but  is  a  "  portion  of  a  wide  system  of  mesoblastic  connective  tissue  which 
surrounds  the  great  vessels  of  the  trunk,  accompanying  their  branches 
from  origin  to  termination,  and  extending,  mainly  in  the  form  of  peri- 
vascular sheaths,  to  all  parts  of  the  body  "  (Anderson  and  Makins).  In 
the  pelvis  the  connective  tissue  is  found  partly  in  the  form  of  a  loose 
areolar  network,  and  partly  in  the  more  condensed  form  of  fasciae.  It 
surrounds  all  the  blood-vessels,  nerves,  and  lymphatics,  as  well  as  the 
ureters ;  and  passes,  as  investing  sheaths,  to  certain  of  these  outside 
the  limits  of  the  pelvic  cavity.  Below,  it  is  shut  off  from  the  perineum 
and  ischio-rectal  fossffi  by  the  pelvic  fascia.  ''This  strong  aponeurosis  is 
attached  to  the  pelvic  wall  between  the  pubic  bones  and  bodies  of  the 
ischia,  along  that  thickening  of  the  obturator  fascia  known  as  the  white 
line.  From  this  it  passes  as  a  continuous  sheet  over  the  levator  ani  and 
coccygeus  muscles  to  the  vagina  in  front,  and  the  rectum  and  coccyx 
behind.  Behind  the  pubic  symphysis  it  is  closely  blended  with  the 
vaginal  orifice  under  the  name  of  the  triangular  ligament.  All  inflam- 
matory exudation  connected  with  the  female  genitals  above  the  vulva 
takes  place  above  this  strong  fascia  "  (Keiller).  The  cellular  area  of  the 
])elvis,  thus  bounded  below,  has  for  its  upper  boundary  the  peritoneum. 
Here,  however,  its  limitation  is  less  strict,  as  it  is  continuous  with  the 
subserous  connective  tissue  of  the  parietal  peritoneum  of  the  abdominal 
cavity.  Turning  now  to  the  distribution  of  the  pelvic  connective  tissue 
we  find  that,  except  perhaps  over  the  fundus  uteri,  it  forms  a  layer 
under  the  entire  pelvic  peritoneum,  parietal  and  visceral.  The  so-called 
"  ligaments  "  of  the  uterus  contain  a  greater  or  less  quantity  of  it  between 
the  peritoneal  folds  of  which  they  are  composed:  and  in  certain  special 
situations  it  may  be  said  to  be  abundant;  for  example,  around  the  supra- 
vaginal portion  of  the  cervix  uteri,  along  the  base  of  the  broad  ligaments, 


4SS  SVST£J/   OF  GYNECOLOGY 

and  between  tlie  bladder  and  the  symphysis  pubis.  In  the  last-named 
situation  it  contains  in  its  meshes  a  varying  quantity  of  fat. 

The  office  of  the  connective  tissue,  in  the  pelvis  as  elsewhere,  is  simply 
"  to  connect  and  support  the  other  tissues,  performing  thus  a  passive 
mechanical  function"  (Schafer). 

The  layer  of  the  connective  tissue  intervening  between  the  vaginal 
roof  and  the  peritoneum  does  not  ordinarily  measure  more  than  about 
one-third  of  an  inch  in  thickness ;  but  the  study  of  frozen  sections  has 
shown  us  that  in  pregnancy  its  thickness  is  greatly  increased.  The  broad 
ligaments  are  gradually  drawn  upwards  during  the  growth  and  develop- 
ment of  the  pregnant  uterus,  until,  at  the  end  of  pregnancy,  they  lie  in 
the  iliac  fossae,  entirely  above  the  brim  of  the  pelvis  ;  and  no  peritoneum 
is  found  dipping  into  the  lateral  parts  of  the  pelvis.  The  space  thus 
vacated  by  the  broad  ligaments  and  the  reflections  of  peritoneum  behind 
and  in  front  of  them  is  filled  up  by  connective  tissue,  so  that  the 
quantity  of  connective  tissue  in  the  pelvis  is  in  the  later  months  of 
pregnancy  enormously  increased.  This  fact,  it  need  scarcely  be  said,  has 
a  most  important  clinical  bearing. 

Etiology.  —  Primary  pelvic  cellulitis  is  always  a  result  of  septic  in- 
fection. Its  most  common  source  is  the  absorption  of  septic  matter 
through  the  lacerations  of  the  cervix  uteri  and  of  the  upper  part  of  the 
vagina  which  occur  during  labour.  Injury  to  the  vagina  results  from  the 
use  of  obstetric  instruments,  especially  the  forceps,  much  more  frequently 
than  is  generally  supposed.  On  many  occasions,  when  examining  cases 
of  puerperal  pelvic  cellulitis  seen  in  consultation,  I  have  discovered 
wounds  of  the  vagina,  entirely  unsuspected  by  the  medical  practitioner 
in  attendance,  which  had  evidently  been  caused  by  the  project- 
ing edge  of  one  of  the  blades  of  the  forceps.  Such  wounds,  if  they 
remain  aseptic,  readily  heal ;  but  it  often  happens  that  septic  matter 
finds  its  way  into  them,  and  then  pelvic  cellulitis  results.  In  rare  cases 
cellulitis  may  commence  in  the  inner  portion  of  the  broad  ligament  im- 
mediately outside  the  uterus  (where  the  connective  tissue  of  the  broad 
ligament  is  thickest)  from  direct  infection  through  the  tissues  of  the 
uterine  wall.  Polk  and  Lewers  have  each  described  a  case  of  this  kind, 
verified  by  post-mortem  examination.  Other  sources  of  infection  are  the 
various  surgical  manipulations  practised  on  the  vagina  and  cervix.  Before 
the  necessity  of  aseptic  precautions  was  understood  and  generally  acted 
upon,  the  most  trifling  surgical  proceedings  in  these  parts  were  apt  to 
Ijc  followed  by  an  attack  of  cellulitis.  Cases  thus  produced  are  now 
happily  rare.  Septic  infection  following  abortion  seldom  gives  rise  to 
primary  pelvic  cellulitis,  for  the  simple  reason  that  the  cervix  uteri  and 
vagina  are  not  exposed  to  injury;  the  cervix  is  not  unduly  stretched 
during  the  passage  of  the  ovum,  and  the  vagina  is  not  wounded  by 
instruments. 

Inasmuch  as  lacerations  of  the  cervix  and  upper  part  of  the  vagina 
('the  fiarts  around  wliich  the  connective  tissue  is  found  in  greatest 
abundance)  are  the  injuries  most  likely  to  be  followed  by  cellulitis,  it 


PELVIC  INFLAMMATION  489 

follows  that  any  surgical  operation  by  which  the  integrity  of  these  tissues 
is  endangered,  such  as  the  removal  of  large  uterine  polypi,  may,  as  in  the 
process  of  parturition,  open  the  way  for  cellulitic  infection.  It  is  obvious 
that  special  danger  is  incurred  if,  at  the  time  of  their  expulsion  or  removal, 
the  polypi  are  undergoing  necrosis. 

In  connection  with  the  etiology  of  cellulitis  it  must  be  remembered 
that  whenever  the  connective  tissue  has  been  subjected  to  bruising,  as 
in  parturition  and  the  expulsion  or  removal  of  large  polypi,  its  power  of 
resistance  to  the  infective  process  has  been  thereby  diminished ;  or,  in 
other  words,  its  susceptibility  to  infection  has  been  increased. 

The  lymphatics  are  the  channels  by  which  the  poison  is  conveyed  to  the 
connective  tissue.  Hence  there  is  always  a  certain  amount  of  lymphan- 
gitis associated  with  cellulitis.  It  is  highly  probable  that  the  lymphatic 
glands  also  are  generally  implicated,  as  Avell  as  the  lymphatic  vessels. 
But  as  both  the  lumbar  glands,  which  receive  the  lymphatics  from  the 
broad  ligaments  and  the  body  of  the  uterus,  and  the  hypogastric  or  pelvic 
glands  which  receive  the  lymphatics  from  the  cervix  uteri  and  upper 
portion  of  the  vagina,  are  out  of  reach  of  the  examining  finger,  we  are 
without  direct  clinical  evidence  of  glandular  enlargement.  We  know, 
however,  that  in  acute  cellulitis  in  other  regions  of  the  body,  where  the 
lymphatic  glands  are  in  situations  in  which  they  can  be  examined  by  the 
sense  of  touch,  glandular  enlargement  is  invariably  found  and  glandular 
suppuration  is  by  no  means  uncommon.  Hence,  we  are  justified  by 
analogy  in  concluding  that  in  pelvic  cellulitis  a  similar  condition  of  things 
usually  obtains.  Moreover,  cases  of  cellulitic  abscess  in  the  pelvis  not 
unfrequently  occur  in  which  the  situation  of  the  abscess  makes  it  highly 
probable  that  the  hypogastric  glands  are  involved  in  the  suppuration. 

Frequency.  —  It  is  not  possible  at  present  to  give  any  exact  state- 
ments as  to  the  frequency  of  pelvic  cellulitis.  It  can  be  stated,  how- 
ever, with  certainty  that,  compared  with  pelvic  peritonitis,  it  is  a  rare 
affection. 

Pathological  Anatomy.  — Pelvic  cellulitis  occurs  with  or  without  the 
formation  of  pus.  In  the  latter  case,  as  in  cellulitis  elsewhere,  there 
is  an  exudation  of  coagulable  lymph,  with  oedema,  into  the  tissue  of  the 
infected  area,  which  at  first  produces  increase  in  bulk  without  manifest 
alteration  of  consistence.  Very  soon,  however,  the  inflamed  tissue  be- 
comes stiff  and  indurated ;  and  at  a  later  stage  the  hardness  is  often  so 
marked  as  to  be  not  inappropriately  compared  with  cartilage.  As  the 
patient  recovers,  the  inflammatory  exudation  gradually  undergoes  absorp- 
tion and  eventually  disappears  altogether.  AVhen  suppuration  occurs  the 
result  is  a  true  pelvic  abscess.  Usually  there  is  a  single  large  abscess 
cavity ;  but  occasionally  several  abscesses  are  found  in  contiguous  por- 
tions of  the  cellular  area. 

Symptoms. — Telvic  cellulitis  is  often  ushered  in  by  a  rigor.  In 
puerperal  cases  this  usually  occurs  on  the  second  or  third  day  after  de- 
livery, but  it  maj^  take  place  later.  In  non-puerperal  cases  the  interval 
between  the  period  of  infection  and  the  first  manifestation  of  symptoms 


490  SYSTEM  OF  GYNECOLOGY 

seldom  exceeds  a  day  or  two.  It  is  the  occurrence  of  this  rigor  or  chill, 
as  the  initial,  symptom,  that  has  given  rise  to  the  popular  but  erroneous 
notion  that  the  disease  may  be  the  result  of  exposure  to  cold.  Simul- 
taneously with  the  rigor,  the  temperature  rises  aud  the  pulse  becomes 
accelerated.  Pain  seldom  occurs  unless  the  inflammation  extend  to  the 
neighbouring  peritoneum.  In  cases  attended  with  suppuration  perhaps 
the  most  marked  symptom  is  the  progressive  emaciation :  this  is  always 
associated  A^dth  pallor  and  with  a  certain  earthy  sallowness  of  the  skin 
which  is  highly  characteristic.  The  skin  over  the  body  generally  is  harsh 
and  dry  and  covered  with  branny  scales,  the  result  of  fine  desquamation. 
The  patient,  in  severe  cases,  looks  extremely  ill.  All  desire  for  food  is 
lost.  The  bowels  are  ordinarily  constipated,  though  occasionally  there  is 
diarrhoea.  There  is  often  marked  mental  depression,  with  an  irritability 
of  disposition  that  may  be  quite  foreign  to  the  patient's  true  character. 
It  is  most  interesting  to  observe  how  quickly  the  symptoms  are  ameliorated 
when  the  pus  is  evacuated  and  the  tension  relieved.  Within  a  few  hours 
the  patient's  aspect  will  have  undergone  an  entire  change,  and  her  irrita- 
bility and  despondency  will  have  disappeared.  If  the  exudation  extend 
to  the  connective  tissue  in  the  neighbourhood  of  the  psoas  and  iliacus 
muscles,  and  still  more,  if  it  involve  the  connective  tissue  elements  in 
the  substance  of  these  muscles,  the  patient  (in  order  to  relax  the  muscles) 
lies  with  the  thigh  of  the  affected  side  bent  upon  the  trunk  and  the  leg 
drawn  up. 

The  general  symptoms  are  those  of  a  subacute  form  of  septicsemia; 
the  local  symptoms  are  often  so  few  and  indefinite  that  the  existence  of 
an  acute  inflammatory  process  within  the  pelvis  may  remain  for  some 
time  unsuspected. 

Physical  Signs.  —  In  the  early  days  of  an  attack  of  acute  pelvic 
cellulitis,  jjhysical  examination  gives  us  but  little  information.  The 
vagina  is  hot  and  tender,  and  its  vessels  may  be  felt  pulsating ;  and  that 
is  all.  After  the  lapse  of  several  days  the  physical  signs  are  those  of 
inflammatory  exudation,  at  first  braAvny  in  consistence  and  afterwards 
densely  hard,  in  the  tissue  of  the  affected  area.  When  the  poison  has 
entered  through  a  wound  in  the  cervix,  the  cervix  is  found  to  have  lost 
its  normal  mobility,  and  the  supravaginal  tissues  on  the  affected  side  are 
found  uniformly  tender  and  more  or  less  hard  and  unyielding.  Owing  to 
their  swollen  condition  they  cause  a  depression  of  the  lateral  fornix  of  the 
vagina  on  that  side,  sometimes  completely  obliterating  it.  It  is  seldom 
that  V)oth  sides  of  tlie  pelvis  are  equally  affected;  but  it  is  by  no  means 
unusual  to  find  the  whole  supravaginal  portion  of  the  cervix  embedded 
in  a  thick  tender  collar  of  indurated  tissue,  which  more  or  less  comi)U!tely 
surrounds  it.  In  the  majority  of  cases  tlie  inflammation  spreads  laterally 
along  the  base  of  the  broad  ligament  of  the  infected  side,  and  then  passes 
forward  to  the  tissue  beneath  the  reflection  of  peritoneum  on  the  anterior 
abdominal  wall.  It  is  at  this  stage  that  an  area  of  uniform  hardness  and 
resistance  can  be  felt  in  the  abdominal  wall  beneath  the  muscles.  This 
hardness  usually  takes  the  form  of  a  broad  band,  measuring  one  and  a 


PELVIC  INFLAMMATION  491 

half  to  two  inches  or  more  in  width,  and  lying  along  the  upper  border  of 
the  inner  portion  of  Poupart's  ligament.  More  rarely  the  area  of  hardness 
is  confined  to  the  supra-pubic  region,  whence  it  may  gradually  extend 
upwards  even  as  far  as  the  umbilicus.  Sometimes  the  exudation  spreads 
upwards  and  outwards  from  above  Poupart's  ligament  into  tlie  iliac  fossa, 
interfering  with  the  action  of  the  psoas  and  iliacus,and  leading  the  patient 
to  keep  the  thigh  flexed  in  order  to  relax  these  muscles.  In  some  instances 
the  inflammation  passes  backwards  instead  of  forwards,  producing  an 
exudation  in  the  tissue  of  one  or  both  utero-sacral  ligaments,  in  the  tissue 
surrounding  the  rectum  and  in  that  beneath  the  peritoneum  lining  the 
posterior  pelvic  wall.  In  these  cases  much  information  can  be  obtained 
from  a  rectal  examination,  when  the  rectum  will  be  felt  whollj^or  partially 
surrounded  with  a  hard  belt  of  exudation.  As  pelvic  cellulitis  is  at  least 
as  common  on  the  left  side  of  the  pelvis  as  on  the  right,  such  an  impli- 
cation of  the  tissue  surrounding  the  rectum  is  by  no  means  unusual. 
Meantime  there  is  no  swelling  in  the  situation  of  Douglas'  pouch,  unless 
the  case  be  complicated  with  pelvic  peritonitis.  When  the  body  of  the 
uterus  is  the  starting-point  of  the  cellulitis,  and  the  broad  ligament  itself 
the  seatof  the  exudation,  bimanual  examination  will  reveal  ahard,  smooth, 
flattened,  slightly  movable  tumour,  by  the  side  of  the  uterus  and  insepa- 
rable from  it,  occasionally  displacing  it  a  little  towards  the  sound  side.^ 

When  there  is  no  suppuration  the  exudation  becomes  absorbed,  and, 
in  uncomplicated  cases,  the  hardness  gradually  disappears,  leaving  no 
trace  behind. 

Pelvic  Abscess. — In  a  considerable  number  of  cases  of  pelvic  cellulitis 
the  inflammation  is  attended  with  the  formation  of  abscess.  The  situation 
of  the  abscess  and  the  position  where  it  may  be  expected  to  point  depend, 
of  course,  upon  the  direction  in  which  the  inflammatory  exudation  lias 
extended.  Taking  the  most  common  case  first,  — that,  namely,  where  the 
inflammation  is  seated  in  the  tissue  at  the  base  of  the  broad  ligament,  and 
passes  forward  beneath  the  peritoneum  as  it  is  reflected  on  tlie  anterior 
abdominal  wall, forminganarea  of  induration  above  Poupart's  ligament, — 
the  presence  of  suppuration  is  manifested  by  the  occurrence  of  oedema  in 
the  skin  over  the  indurated  area,  Avhich  pits  on  pressure  ;  bj'the  signs  of 
deep-seated  fluctuation,  and  by  the  eventual  pointing  of  the  abscess  at  a 
site  usually  a  little  above  Poupart's  ligament.  This  site  can  often  be 
detected  long  before  the  pus  has  reached  the  surface,  by  passing  the  tip 
of  the  finger  carefully  over  the  indurated  area,  where  it  can  be  recognised 
as  a  soft  depression  in  the  midst  of  the  surrounding  hardness.  Of  twenty- 
two  cases  of  cellulitic  abscess  treated  at  St.  Thomas'  Hospital  during  the 
years  1889-0.3,  the  abscess  pointed  above  Poupart's  ligament  in  no  fewer 
than  eighteen.  Whenever  pelvic  cellulitis  exteiuls  in  such  a  direction  as 
to  cause  aniuduration  in  the  abdominal  wall — whether  that  induration  be 
in  front  of  the  bladder  (supra-pubic),  or  above  Poupart's  ligament,  or  over 
the  iliac  fossa — it  ma}^  reasonably  be  expectedthat,  if  anabscess  be  formed, 

1  An  exap;£;erato(1  iinpdrtance  lias  been  attached  to  lateral  displarenient  of  the  uterns  as 
a  distinctive  sign  of  jielvic  cellulitis ;  it  occurs  but  rarely,  and  is  of  little  diagnostic  value. 


492  SYSTEM  OF  GYNECOLOGY 

it  will  point  on  the  external  surface  of  the  body  at  the  site  of  the  indura- 
tion. "  Unfortunately,  pelvic  cellulitis,  as  has  already  been  stated,  some- 
times extends  in  a  backward  instead  of  in  a  forward  direction,  following 
probably  the  course  of  the  lymphatics;  if,  under  such  circumstances,  sup- 
puration occur,  the  result  is  less  satisfactory:  an  abscess  is  then  formed 
beneath  the  peritoneum  covering  the  back  of  the  pelvis,  and,  as  the  con- 
tents of  such  an  abscess  have  no  direct  access  to  a  free  surface,  relief  is 
much  longer  delayed  and  extensive  burrowing  is  almost  inevitable. 
Extension  into  the  iliac  fossa  and  the  loin  is  more  particularly  apt  to  take 
place  when  the  posterior  pelvic  wall  is  thus  the  seat  of  an  abscess,  the 
abscess  pointing  either  at  the  iliac  crest  or  above  it.  Sometimes  the  pus 
leaves  the  pelvis  by  the  sciatic  notch,  and  follows  the  course  of  the  sciatic 
and  gluteal  vessels ;  in  other  instances  it  makes  its  appearance  in  Scarpa's 
triangle,  having  found  its  way  by  the  side  of  the  femoral  vessels.  By 
whatever  route  the  pus  makes  its  way  out  of  the  pelvis  it  does  so  by 
folloAving  the  track,  not  of  nerves  or  of  tendons,  but  of  the  blood-vessels 
and  other  parts,  such  as  the  ureter,  which  are  accompanied  by  a  prolon- 
gation of  the  connective  tissue  as  they  enter  or  leave  the  pelvis.  It  is 
sometimes  stated  that  a  pelvic  abscess  may  follow  the  course  of  the  psoas 
muscle ;  but  when  matter  burrows  along  the  psoas  it  comes  not  from  a 
cellulitic  abscess,  but  from  dead  bone. 

The  statement,  so  commonly  made,  that  cellulitic  abscesses  frequently 
burst  into  the  rectum,  the  vagina,  and  the  bladder,  appears  to  rest  on 
very  slender  foundation.  Many  of  the  cases  quoted  in  its  support  belong 
to  a  time  when  little  was  known  of  the  pathology  of  pelvic  inflammation, 
and  on  reading  them  in  the  light  of  our  present  knowledge  it  is  easy  to 
see  that  at  least  a  considerable  number  of  the  cases  reported  as  cellulitic 
abscesses  were  really  cases  of  intraperitoneal  suppuration,  originating  in 
suppurative  disease  either  of  the  Fallopian  tubes  or  the  ovaries.  There 
is,  however,  no  anatomical  reason  why  cellulitic  abscesses  should  not 
occasionally  discharge  themselves  into  the  rectum,  vagina,  or  even  the 
bladder ;  and  some  of  the  cases  on  record  appear  to  be  genuine  examples 
of  such  an  occurrence. 

The  usual  time  for  an  abscess  to  point  is  from  the  seventh  to  the 
twelfth  week.  The  earliest  period  at  which  I  have  known  pointing  to 
occur  is  five  weeks,  the  latest  fourteen. 

Diffuse  Pelvic  Suppia'ation. — In  connection  with  this  subject  of  abscess 
in  the  pelvic  connective  tissue  I  must  mention  a  peculiarly  malignant  form 
of  pelvic  inflammation,  occiirring  for  the  most  part  in  puerperal  women, 
in  which,  in  addition  to  other  lesions  significant  of  tlie  virulence  of  the 
septic  infection,  there  are  found  after  death  multiple  abscesses  in  the 
connective  tissue,  many  of  them  so  small  as  easily  to  escape  detection 
unless  carefully  looked  for.  This  affection  has  all  the  characters  of 
phlegmonous  erysipelas.  The  tissues  involved  are  oedematous  and  of 
a  livid  hue;  suppurating  thrombi  are  found  in  the  veins,  and  the 
lymphatics  are  seen  to  be  acutely  inflamed.  In  a  considerable  proportion 
of  the  cases  the  ovaries  are  found  to  be  in  a  state  of  suppuration,  and 


PELVIC  INFLAMMATION  493 

there  is  usually  evidence  of  extension  of  the  inflammation  to  the  pel- 
vic peritoneum.  Such  cases  are  attended  with  all  the  symptoms  of 
septicaemia  in  its  most  intense  form  and  are  rapidly  fatal. 

Diagnosis.  —  As  pelvic  cellulitis  is  usually  unattended  with  pain,  it 
has  often  nuide  considerable  progress  before  its  presence  is  suspected. 
Puerperal  Avomen  very  naturally  show  a  repugnance  to  vaginal  examina- 
tions, owing  to  the  tenderness  of  the  external  genitals  and  the  presence 
of  the  lochia.  When  the  puerperium  runs  a  normal  course  this  feeling 
is  very  properly  respected,  and  the  medical  attendant  is  justified  in 
abstaining  from  the  infliction  of  the  unnecessary  pain  and  annoyance 
occasioned  by  digital  examination.  But  it  cannot  be  too  strongly 
pointed  out  that  the  justification  for  this  abstention  ceases  when 
symptoms  of  pyrexia  supervene,  and  when  it  becomes  evident  that  the 
ordinary  coarse  of  recovery  is  interrupted.  A  temporary  elevation  of 
temperature  may,  of  course,  occur  from  such  causes  as  constipation  and 
the  influence  of  the  emotions.  As  soon,  however,  as  the  medical 
attendant  has  satisfied  himself  that  the  symptoms  are  not  of  this 
transient  nature,  it  becomes  his  duty,  especially  if  the  lochia  be  offensive, 
to  make  a  thorough  examination  not  only  of  the  vagina,  but  of  the  in- 
terior of  the  uterus  which,  during  the  first  ten  days  after  delivery,  can 
easily  be  explored  by  the  bimanual  method  without  resorting  to 
artificial  dilatation.  If  the  result  of  this  examination  be  the  discovery 
of  a  fragment  of  placental  tissue  or  a  decomposing  blood-clot  within  the 
uterus  he  will  of  course  remove  it,  and  adopt  suitable  measures  for 
cleansing  and  disinfecting  the  uterine  cavity,  with  the  almost  certain 
prospect  of  thereby  promptly  relieving  the  symptoms.  If  not,  he  will 
have  eliminated  the  most  probable  cause  for  the  pyrexia,  and  will,  a-t  the 
same  time,  have  had  an  opportunity  of  detecting  any  swelling  or  other 
morbid  condition  in  the  tissues  surrounding  the  uterus  and  vagina. 
Within  a  very  few  days  of  the  onset  of  the  attack  the  physical  signs  of 
pelvic  cellulitis  become  sufficiently  Avell  marked  to  leave  no  room  for 
doubt  as  to  the  diagnosis;  and  the  discovery  of  a  laceration  of  the 
cervix  or  of  the  vaginal  Avail  will  usually  indicate  the  probable  channel 
through  Avhich  the  infection  gained  an  entrance.  Frequently  one  of 
the  earliest  signs  of  cellulitis  is  an  impaired  mobility  of  the  cervix,  Avith 
tenderness  and  sAvelling  on  one  side  of  it.  A  little  later  the  inflamed 
tissue  becomes  stiff,  and  the  stiffness  quickly  increases  into  a  Avell-defined 
hardness.  The  inflammation  may  gradually  extend  all  round  the  upper 
part  of  the  cervix ;  or  may  spread  outwards  along  the  base  of  the  broad 
ligament  of  the  affected  side,  depressing  the  lateral  fornix  of  the  vagina 
and  sometimes  obliterating  it.  At  a  later  stage  the  induration  Avill,  in 
the  majority  of  cases,  extend  to  the  sub-peritoneal  connective  tissue 
above  Poupart's  ligament,  and  become  evident  on  external  examination 
as  a  braAvny,  tender  sAvelling  in  that  region.  The  diagnosis  of  the  pres- 
ence of  pus  has  already  been  described.  When  the  direction  taken 
by  the  cellulitis  is  toAvards  the  posterior  part  of  the  pelvis,  an  examina- 
tion per  vaginam  of  the  posterior  pelvic  AA'-all  on  both  sides  Avill  usually 


494  SYSTEM  OF  GYNECOLOGY 

reveal  a  diffused  fulness  and  hardness  on  the  affected  side  as  compared 
with  the  sound  side ;  whilst  a  rectal  examination  will,  owing  to  the 
infiltration  of  the  tissues  surrounding  the  middle  portion  of  the  rectum, 
render  the  diagnosis  still  more  certain. 

In  the  rarer  case  of  the  broad  ligament  proper  being  the  part 
affected,  the  diagnosis  is  made  by  finding  the  mobility  of  the  body  of 
the  uterus  impaired  by  the  presence  of  a  more  or  less  flattened  mass  of 
induration  on  one  side  of  the  body  and  continuous  with  it.  This  mass 
is  capable  of  a  certain  amount  of  movement  backwards  and  forwards 
when  held  between  the  two  examining  hands.  It  does  not  extend  into 
the  posterior  pelvic  fossa. 

Except  along  the  plane  of  tissue  between  the  cervix  uteri  and  the 
bladder,  the  cellular  area  of  one  side  of  the  pelvis  is  more  or  less  shut 
off  from  direct  communication  with  that  of  the  other  side  by  the  close 
attachment,  in  the  middle  line,  of  the  visceral  peritoneum  to  the  bladder, 
fundus  uteri,  and  rectum.  Hence  pelvic  cellulitis  is  for  the  most  part 
unilateral. 

The  differential  diagnosis  between  pelvic  cellulitis  and  pelvic  peri- 
tonitis will  be  more  conveniently  considered  when  the  physical  signs 
of  the  latter  affection  have  been  described.  The  only  other  conditions 
likely  to  be  confounded  with  pelvic  cellulitis  are  heematoma  of  the  broad 
ligament  and  myoma  of  the  uterus.  In  haematoma  of  the  broad  liga- 
ment there  is  an  effusion  of  blood  into  the  connective  tissue  of  the 
ligament,  which  forms  a  slightly  movable,  somewhat  flattened  tumour 
by  the  side  of  the  uterus  and  continuous  with  it,  simulating  that  rare 
variety  of  pelvic  cellulitis  which  affects  the  broad  ligament  proper. 
The  history  of  the  case  and -the  absence  of  symptoms  of  severe  illness 
will,  as  a  rule,  serve  sufficiently  to  distinguish  a  hsematoma  from  an  in- 
flammatory condition.  Haematoma  occurs  suddenly,  either  from  the 
rupture  of  a  jjregnant  tube  into  the  connective  tissue  between  the  layers 
of  the  mesosalpinx,  or  from  rupture  of  a  varicose  vein  in  the  broad 
ligament.  In  either  case  the  onset  is  usually  marked  by  sudden  pain 
and  faintness  and  usually  also  by  an  attack  of  vomiting.  In  the  case 
of  rupture  of  a  pregnant  tube  one  or  more  menstrual  periods  will 
probably  have  been  missed,  and  attacks  of  pain  will  have  occurred  in 
the  lower  part  of  the  abdomen,  generally  on  one  side,  with  slight 
irregular  haimorrhages  from  the  uterus.  The  effect  of  a  sudden  out- 
pouring of  blood  into  the  tissues  of  the  broad  ligament,  so  far  as  the 
temperature  and  pulse  are  concerned,  is  transient.  Hence  when  the 
haematoma  has  existed  for  a  few  days  the  temperature  and  pulse 
become  normal.  The  possibility,  however,  of  the  haematoma  becoming 
infected  and  undei'going  suppuration  must  be  borne  in  mind.  Should 
this  occur,  the  symptoms  will  be  similar  to  those  of  pelvic  abscess  due 
to  cellulitis. 

In  regard  to  myoma  of  the  uterus,  it  certainly  seems  extremely 
unlikely  that  this  disease  could  ever  be  mistaken  for  a  cellulitic 
exudation.     Now  and  then,  however,  a  case  occurs  in  which  a  myoma 


PELVIC  INFLAMMATION  495 

develops  itself  laterally  between  the  layers  of  the  broad  ligament,  fixing 
the  uterus  and  forming  a  more  or  less  hard  tumour  directly  continuous 
with  it.  Should  a  localised  peritonitis  take  place  around  such  a  tumour, 
or  should  such  a  tumour  become  inflamed  or  gangrenous,  the  diagnosis 
might  be  attended  with  considerable  difficulty.  A  myoma  in  the 
posterior  wall  of  the  uterus  could  scarcely  give  rise  to  misleading  signs  ; 
large  inflammatory  exudations  into  the  connective  tissue  behind  the 
cervix  uteri  being  extremely  rare.  Similarly,  a  myoma  in  the  anterior 
wall  of  the  uterus  is  not  likely  to  be  mistaken  for  cellulitis,  the  signs  of 
cellulitic  exudation  between  the  bladder  and  the  upper  part  of  the  cervix 
being  well  marked  and  highly  characteristic. 

Prognosis.  —  Except  in  the  diffuse  variety  of  pelvic  cellulitis,  in 
which  the  cellulitis  is  only  a  part  of  a  general  septic  process  of  the  most 
acute  and  fatal  type,  the  disease  usually  terminates  in  recovery.  As 
soon  as  the  fever  subsides  the  exudation  begins  to  undergo  absorption, 
and  under  favourable  circumstances  it  will  have  entirely  disappeared  in 
a  few  weeks.  Unlike  pelvic  peritonitis,  cellulitis,  when  uncomplicated 
by  peritonitis,  leaves  no  unpleasant  results  such  as  adhesions  or  dis- 
placements. The  recovery  is  complete.  An  attack  of  pelvic  cellulitis 
is  therefore  no  bar  to  subsequent  pregnancy. 

If  the  fever  do  not  subside  in  the  course  of  five  or  six  weeks  sup- 
puration has  probably  occurred.  The  duration  and  progress  of  the 
illness  will  then  largely  depend  on  the  direction  that  the  pus  may  take 
in  its  efforts  to  reach  the  surface.  In  the  large  majority  of  cases  the 
abscess  will  point  above  Poupart's  ligament,  where  it  can  be  opened 
easily  and  satisfactorily  before  much  burrowing  has  occurred.  These 
cases  almost  invariably  do  well.  In  the  rarer  cases,  where  suppuration 
occurs  at  the  back  of  the  pelvis,  the  pus  is  longer  in  reaching  a  surface 
and  is  apt  to  burrow  in  different  directions.  Such  cases  often  last  a 
long  time  and  are  very  trying.  They  are  more  apt,  too,  to  be  com- 
plicated by  extensions  to  the  peritoneum. 

It  is  often  stated  that  troublesome  sinuses  are  a  not  infrequent 
result  of  pelvic  abscess.  I  have  never  myself  yet  seen  a  troublesome 
sinus  result  from  opening  a  cellulitic  abscess  in  the  pelvis  on  the  surface 
of  the  body  ;  and  I  strongly  suspect  that  the  cases  in  which  such  sinuses 
have  occurred  have  not  been  cellulitic  abscesses,  but  suppurating  ovarian 
cysts,  or  other  non-cellulitic  forms  of  pelvic  suppuration.  Similarly, 
cellulitic  abscesses  are  said  to  burst  into  the  rectum,  vagina,  and  bladder, 
and  to  form  fistulas  in  consequence.  I  believe  this  assertion  to  be, 
generally  speaking,  ill-founded.  It  must  be  a  very  rare  occurrence  for 
cellulitic  abscesses  to  open  into  these  organs ;  the  abscesses  that  com- 
monly open  into  them  are  the  result  of  suppuration  in  the  tubes  or 
ovaries.  It  is  easy  to  understand  that  such  abscesses  will  not  un- 
frequently  be  followed  by  fistula.  But  under  ordinary  circumstances 
a  true  pelvic  abscess,  that  is,  a  cellulitic  abscess,  discharges  its  con- 
tents and  disappears. 


496  SVSTEA/  OF  GYNECOLOGY 

Treatment.  —  If  the  views  here  set  forth  concerning  the  uniformly 
septic  origin  of  pelvic  cellulitis  be  correct,  the  preventive  treatment  of 
the  disease  may  be  summed  up  in  a  very  few  words  :  it  will  consist  in  a 
strict  regard  to  asepsis,  or  surgical  cleanliness,  in  all  midwifery  cases 
and  in  all  surgical  manipulations  of  the  female  genital  organs.  If  free- 
dom from  infection  could  be  ensured  to  the  parturient  woman  pelvic 
cellulitis  would,  for  all  practical  purposes,  disappear  ;  and  if  a  similar 
freedom  could  be  extended  to  every  woman  who  is  submitted  to  vaginal 
examination  and  manipulation  the  disappearance  of  the  disease,  as  a 
primary  affection,  would  be  complete. 

It  is  very  doubtful  whether,  when  once  an  attack  of  pelvic 
cellulitis  has  been  lighted  up,  it  is  possible  to  modify  the  course 
of  the  disease  by  any  medication,  internal  or  external.  In  this  un- 
certainty it  behoves  us  at  least  to  be  careful  not  to  do  our  patients 
any  harm.  The  remedies  against  the  abuse  of  which  I  consider  it 
specially  desirable  to  utter  a  word  of  warning  are  opium  and  the  anti- 
pyretics. Opium  in  one  form  or  another  is  frequently  given  as  a 
matter  of  routine.  The  result  is  a  further  disturbance  of  the  already 
disturbed  digestive  functions,  and  an  aggravation  of  one  of  the  principal 
difficulties  with  which  the  physician  has  to  contend,  namely,  constipa- 
tion. Opium  and  morphia  should  be  reserved  for  cases  complicated  with 
peritonitis,  and  therefore  attended  with  pain  ;  and  should  be  given  with 
the  sole  object  of  relieving  pain.  Similarly,  antipyretics  (including 
quinine  when  administered  in  large  doses)  should  be  reserved  for  the 
rare  occasions  when  the  temperature  is  so  high  as  to  constitute  in  itself 
a  source  of  danger.  When  there  is  no  special  therapeutic  indication,  a 
simple  saline  mixture  containing  liquor  ammonise  acetatis  or  potassium 
citrate,  or  some  acidulated  vegetable  tonic,  will  be  the  safest  and  most 
suitable  medicine.  The  state  of  the  bowels  should  receive  the  most 
careful  attention.  A  regular  course  of  aperient  medicine  at  bedtime 
will  almost  always  be  required,  and  will  often  need  the  supplement  of  a 
soap-and-water  enema  in  the  morning.  The  patient's  comfort  will  much 
depend  on  the  care  with  which  fsecal  accumulations  are  avoided.  The 
question  of  feeding  is  of  equal  importance.  In  the  acuter  stages  a 
farinaceous  diet  is  j)roper,  but  as  soon  as  possible  fish  or  fowl  should 
be  given,  and  a  persistence  of  febrile  tem])erature  need  be  no  bar  to  a 
meat  diet  if  the  patient  can  take  it.  The  tendency  to  emaciation  calls 
for  generous  feeding,  and  concentrated  foods  are  only  to  be  used  when 
ordinary  food  cannot  be  taken. 

Local  applications  to  the  lower  parts  of  the  abdomen  are  only 
necessary  when  indiu-ation  is  to  be  felt  in  that  situation,  or  when  pain 
is  present.  Hot  flannel  fomentations  aft'ord  most  relief;  it  is  well  to 
alternate  them  with  the  application  of  a  thick  layer  of  dry  cotton  wool, 
kept  in  place,  if  necessary,  by  a  flannel  bandage.  The  application  of 
glycerine  and  belladonna,  at  present  much  in  vogue,  is  of  very  doubtful 
value.  It  is  inferior  to  hot  fomentations  and  poultices  as  a  means  of 
relieving  pain. 


PELVIC  INFLAMMATION  AfTJ 

The  hot  vaginal  douche,  administered  at  a  temperature  of  110°  to 
115°  F.,  was  highly  extolled  by  Dr.  Emmet  of  New  York,  who  believed 
it  to  be  exceedingly  efficacious  in  promoting  absorption  of  the  inflam- 
matory exudation.  Chiefly  owing  to  his  persistent  advocacy,  it  has 
,  become  more  popular  than  any  other  form  of  local  application  ;  though 
its  remedial  effect  is  very  doubtful,  it  is  often  a  source  of  comfort  to 
the  patient,  and  if  administered  gently  can  at  any  rate  do  no  harm. 
Vaginal  tampons  of  glycerine  have  for  many  years  been  in  favour  as 
an  additional  means  of  hastening  the  disappearance  of  inflammatory 
thickening.  More  recently,  tampons  soaked  in  a  15  per  cent  or  20  per 
cent  solution  of  ichthyol  in  glycerine  have  been  recommended  for  the 
same  purpose.  The  remedial  value  of  these  applications  is  probably 
very  slight. 

When  matter  forms  the  case  is  to  be  dealt  with  on  recognised  sur- 
gical principles ;  the  abscess  should  be  opened  as  soon  as  fluctuation  is 
detected,  or  there  is  the  faintest  indication  of  pointing.  In  ordinary 
cases  the  drainage  tube  is  required  for  a  very  few  days  only.  In  the 
great  majority  of  cases  the  incision  will  be  made  externally.  In  this 
form  of  pelvic  suppuration  abdominal  section  is,  in  my  experience, 
entirely  uncalled  for.  Should  the  abscess  point  in  the  vagina,  it  must 
of  course  be  opened  there.  Most,  however,  of  the  fluctuating  swellings 
felt  through  the  vaginal  roof  are  not  cellulitic  abscesses,  but  come  into 
quite  a  different  category. 

Before  concluding  the  subject  of  treatment,  I  desire  to  call  attention 
to  the  need,  in  those  cases  in  which  the  patient  lies  day  after  day  with 
the  knee  and  thigh  flexed,  of  guarding  against  permanent  contraction  of 
the  knee-joint.  This  distressing  result  may  generally  be  avoided  by 
instructing  the  nurse  to  place  her  hand  beneath  the  heel,  to  raise  it 
sufficiently  high  to  straighten  the  knee,  and  to  hold  it  in  this  position 
for  a  few  minutes  twice  a  day. 

Chroxic  Pelvic  Cellulitis 

Chronic  pelvic  cellulitis  does  not  exist  as  an  independent  affection,  or 
as  a  sequel  to  the  acute  disease  above  described ;  but  it  occurs  occasionally 
as  a  secondary  result  of  purulent  salpingitis  or  other  intrapelvic  suppura- 
tive inflammation.  It  only  involves  the  parts  immediately  contiguous  to 
the  inflamed  structures,  and  never  gives  rise  to  the  broad  band  of  indura- 
tion in  the  lower  part  of  the  anterior  wall  of  the  abdomen  so  common 
in  the  primary  affection. 

The  induration  to  which  it  does  give  rise  introduces,  of  course,  for 
the  time  being,  an  element  of  obscurity  into  the  diagnosis  of  deep-seated 
inflammatory  lesions  in  the  pelvis ;  but  it  generally  subsides  imder  the 
influence  of  rest,  thus  at  the  same  time  establishing  its  true  nature,  and 
removing  the  difficulty  interposed  in  the  way  of  a  satisfactory  bimanual 
examination. 

This  variety  of  pelvic  cellulitis  is  seldom  or  never  attended  Avith 

2k 


498  SYSTEM  OF  GYNECOLOGY 

cellulitic  abscess ;  it  is  characterised  chiefly  by  oedema  and  small-celled 
infiltration  of  the  connective  tissue  concerned. 


Pelvic  Peritonitis 
(Ststoxyms.  —  Perimetritis,  Perisalpingitis,  Perioophoritis) 

Definition  and  Nature.  —  Pelvic  peritonitis  is  an  inflammation  of  that 
portion  of  the  peritoneum  which  is  situated  Avithin  the  pelvis.  It  is  a 
much  more  common  affection  than  pelvic  cellulitis,  and  is  perhaps  met 
with  more  frequently  than  any  other  inflammatory  disease  in  the  pelvis. 
In  the  vast  majority  of  cases  (if  not  indeed  in  all)  it  is  an  infective 
process,  due  either  to  the  presence  of  micro-organisms  or  to  their  chemi- 
cal products.  Its  action  may,  nevertheless,  be  regarded  as  in  the  main 
beneficial.  Not  only  is  it,  in  itself,  an  effort  on  the  part  of  the  organism 
to  resist  and  do  battle  with  the  invading  foe,  but,  by  erecting  barriers 
around  the  diseased  area,  it  tends  to  narrow  and  confine  the  field  of  in- 
fection and  thus  to  shield  the  neighbouring  structures  from  damage. 

In  his  Lettsomian  Lectures  for  1894,  delivered  before  the  Medical 
Society  of  London,  Mr.  Frederick  Treves  emphasises  very  forcibly  this 
view  of  the  nature  of  peritonitis.  "  The  purpose  of  peritonitis,"  he 
says,  "  is  towards  the  saving  of  life,  and  not  towards  the  destruction 
of  it."  This  purpose  is  not  always  fulfilled.  The  poison  may  be  too 
virulent,  or  may  be  present  in  too  great  quantity  for  the  inflammatory 
process  to  cope  with  it  successfully ;  or  again  the  inflammatory  process 
itself  may  be  excessive,  and,  like  most  agencies  that  are  powerful  for 
good,  may  occasionally  be  powerful  also  for  harm. 

Etiology.  —  Pelvic  peritonitis  probably  never  occurs  otherwise  than 
as  a  result  or  complication  of  some  pre-existing  disease  within  the  pelvis. 
Xot  unfrequently,  however,  it  is  the  first  indication  of  the  presence  of 
such  disease ;  for  the  symptoms  of  peritonitis  are  for  the  most  part  acute 
and  of  a  character  to  compel  attention,  whereas  those  of  the  original 
disease  are  often  so  slight  as  to  be  scarcely  noticeable.  Hence  it  happens 
that  in  many  cases,  until  an  operation  or  an  autopsy  discloses  the  disease 
which  was  its  starting-point,  all  we  can  say  with  certainty  is  that  pelvic 
peritonitis  is  present.  Under  such  circumstances  it  is  not  surprising 
that  pelvic  peritonitis  was  for  a  long  time,  and  by  some  persons  is  still 
regarded  as  Ijeing,  occasionally  at  least,  a  primary  idiopathic  inflamma- 
tion, the  result  of  such  simple  causes  as  injury,  exposure  to  cold,  or  the 
sudden  arrest  of  menstruation. 

As  our  knowledge  advances  it  is  becoming  more  and  more  doubtful 
whether  this  is  over  the  case.  It  is  true  that  instances  occur  in  which 
no  pre-existing  disease  is  discovered ;  l)ut  the  number  of  such  cases  is 
diminisliing  so  rapidly  that  the  failure  to  discover  it  in  a  pai'ticular  case 
is  much  more  likely  to  Ijc  du(!  to  imperfections  in  our  knowledge  and  in 
our  powers  of  observation  than  to  its  non-existence. 


PELVIC  INFLAMMATION  499 

Salpingitis  and  its  Complications.  —  In  the  vast  majority  of  cases, 
pelvic  peritonitis  in  woman  is  the  result  of  inflammation  of  the  Fallo- 
pian tube.  Other  causes  will  be  pointed  out  presently ;  this,  being  much 
the  most  common  one,  claims  our  first  and  chief  attention. 

The  mucous  membrane  lining  the  Fallopian  tube  is,  at  the  abdominal 
ostium  of  the  tube,  continuous  with  the  peritoneum  ;  whilst  at  the  inner 
or  uterine  end  of  the  tube  it  is  continuous  with  the  mucous  meml)rane 
lining  the  uterine  cavity.  Thus  there  is  direct  communication  between 
the  uterus  and  vagina  on  the  one  hand  and  the  peritoneum  on  the  other. 
Owing  to  the  continuity  of  its  lining  membrane  with  that  of  the  uterus 
and  vagina,  the  Fallopian  tube  is  exposed  to  constant  risk  of  infection, 
and  the  tendency  of  acute  infective  endometritis,  whether  septic, 
gonorrhoeal,  or  tubercular  is  to  spread  to  and  involve  the  tube.  From 
the  mere  fact  of  the  direct  continuity  of  the  structures  concerned  the 
extension  of  the  infection  to  the  peritoneum  is  rendered  almost  inevita- 
ble; but  the  risk  is  still  further  increased  by  the  peculiar  anatomical 
position  of  the  Fallopian  tube  in  the  human  subject.  No  other  mucous 
canal  in  the  body  is  similarly  situated.  When,  for  example,  the  mucous 
membrane  lining  the  uterus  is  inflamed,  the  patency  of  the  cervical  canal 
provides  a  natural  outlet  for  the  morbid  secretions.  In  the  Fallopian 
tube  there  is  no  such  natural  outlet.  The  uterine  end  of  the  tube, 
under  normal  circumstances,  has  a  lumen  only  just  large  enough  to 
admit  a  fine  bristle.  It  Avill,  therefore,  be  readily  understood  that  a 
very  slight  amount  of  swelling  of  the  mucous  membrane,  such  as  is 
probably  inseparable  from  the  mildest  inflammatory  attack,  may  block 
this  end  completel}^  Hence,  as  an  outlet  for  inflammatory  secre- 
tions, the  uterine  orifice  may  be  regarded  as  practically  non-existent. 
If  there  is,  therefore,  any  outlet  for  them  at  all  it  is  into  the  peritoneal 
cavity.  It  is  this  absence  of  a  suitable  outlet  for  the  morbid  secretions 
of  the  tube,  and  the  continuity  of  the  lining  membrane  of  the  tube  with 
the  peritoneum,  that  together  give  to  the  inflammatory  affections  of  the 
tube  such  an  exceptional  importance,  and  make  pelvic  peritonitis  so 
constant  a  sequel  of  salpingitis. 

There  are  other  ways,  besides  direct  extension  and  the  escape  of 
inflammatory  products,  in  which  pelvic  peritonitis  may  result  from  in- 
flammation of  the  Fallopian  tiibe.  It  is  by  no  means  an  uncommon  result 
of  the  inflammatory  process  for  the  abdominal  ostium  of  the  tul)e  to  be- 
come sealed  by  adhesions,  or  by  inflammatory  changes  in  the  fimbriae. 
The  morbid  secretions  are  then  retained  within  the  tube,  which  thus 
becomes  a  centre  around  which  the  inflammatory  process  spreads  through 
the  wall  of  the  tube  to  the  neighbouring  tissues,  and  chiefly  to  the  peri- 
toneum. Even  if  this  extension  do  not  immediately  occur,  the  diseased 
tube  is  constantly  liable  to  fresh  inflammatory  attacks  from  slight  causes, 
and  these  may  at  any  time  extend  to  the  peritoneum.  If  tlic  pent-up 
secretion  consist  of  pus,  as  is  frequently  the  case,  not  only  is  the  liability 
to  recurrent  attacks  of  pelvic  ])eritonitis  more  marked  than  when  the 
accumulation  is  merely  serous  or  niuco-purulent,  but  there  is  the  added 


SYSTEM  OF  GYNECOLOGY 


danger  of  ulceration  of  the  tube  wall  witli  the  possibility  of  the  pus 
escaping  into  the  peritoneum  by  perforation. 

Sometimes  the  inflamed  Fallopian  tube  infects  the  ovary,  causing  it 
to  suppurate,  and  a  fresh  source  of  danger  to  the  peritoneum  is  thus  pro- 
duced. The  Fallopian  tube  must  still  be  regarded  as  the  starting-point ; 
but  instead  of  affecting  the  peritoneum  directly,  it  does  so  in  this  instance 
indirectly,  through  the  medium  of  the  inflamed  ovary.  Under  such 
circumstances  the  inflamed  tube  and  ovary  may  both  act  as  the  sources 
of  pelvic  peritonitis;  but,  occasionally,  the  tube,  after  infecting  the 
ovary,  so  far  recovers  as  to  be  itself  no  longer  a  centre  of  fresh  mischief, 
and  an  attack  of  peritonitis  may  then  be  due  directly  to  the  ovarian 
condition.  Secondary  infection  of  the  ovary  appears  to  be  particularly 
apt  to  occur  when  the  ovary  is  already  the  seat  of  cystic  disease ;  and 
simple  abscess  of  the  ovary  is  much  less  common  than  suppuration  in 
an  ovarian  cyst.  The  most  usual  mode  of  infection  is  through  the  cyst 
wall,  at  a  spot  where  it  has  become  adherent  to  the  diseased  tube.  Occa- 
sionally, however,  infection  takes  place  by  an  ulcerative  process,  which 
allows  the  contents  of  the  suppurating  tube  to  escape  suddenly  by  per- 
foration into  the  interior  of  the  cyst.  This  is  the  ordinary  way  in  which 
a  tubo-ovaricm  abscess  is  formed^.  Such  a  sudden  extension  of  the  suppura- 
tive process  invariably  provokes  a  fresh  outburst  of  peritonitis,  the 
attack  being  usually  much  more  severe  and  dangerous  than  any  that  has 
preceded  it.  A  still  more  alarming  peritonitis  is  set  up  when  the  con- 
tents of  a  suppurating  tube  or  of  a  suppurating  ovary  escape  by  ulcera- 
tion into  the  peritoneal  cavity.  Fortunately  it  very  seldom  happens 
that  such  an  escape  takes  place  primarily  into  the  general  peritoneal 
cavity,  so  as  to  cause  a  diffuse  suppurative  peritonitis :  the  escape  usu- 
ally occurs  into  a  space  limited  by  adhesions,  and  results  in  an  intra- 
peritoneal abscess.  An  abscess  so  formed  rapidly  enlarges,  and,  if 
allowed  to  go  on  and  the  patient  survive,  eventually  bursts,  according  to 
its  situation,  either  into  some  neighbouring  canal  or  viscus,  or  into  the 
general  peritoneal  cavity,  or  on  the  surface  of  the  body. 

Although  suppuration  of  an  ovarian  cyst  is  usually  the  result  of 
infection  from  an  inflamed  Fallopian  tube,  it  may  occur  independently 
of  tubal  disease.  There  is  reason  to  believe,  for  example,  that  the 
infection  is  occasionally  due  to  the  contiguity  of  the  rectum  or  some 
other  portion  of  the  intestine.  This  is  especially  likely  to  happen  when 
the  tissues  have  been  injured  by  bruising,  as  in  the  process  of  parturi- 
tion. Peritonitis  may  also  result  from  twisting  of  the  pedicle  of  an 
ovarian  tumr)ur.  Experience  shows  that  this  accident  —  with  consequent 
strangulation,  intra-cystic  ha;morrhage  and  inflammation  or  necrosis,  ac- 
cording to  tlie  degree  of  strangulation  —  is  particularly  apt  to  take  place 
during  7)arturition.  Hence,  whenever  puerperal  jjeritonitis  arises,  the 
possibility  of  its  source  in  this  accident  should  be  borne  in  mind.  That 
an  ovarian  tumour  was  not  previously  known  to  exist  by  no  means 
excludes  it  from  consideration. 

New  Growths,  etc.  —  Apart  from  these  complications,  any  new  growth 


PELVIC  INFLAMMATION  501 

in  the  pelvis  may,  by  its  mere  presence,  set  up  peritonitis.  The  frequency 
of  adhesions  in  ordinary  cystic  disease  of  the  ovary  is  sufficient  proof  of 
this.  But  tumours  vary  considerably  in  their  tendency  to  excite  the 
inflammatory  process  in  the  surrounding  peritoneum.  Thus  it  is  excep- 
tional to  meet  with  peritonitis  as  a  result  of  the  presence  of  uterine 
myomas,  even  if  very  large,  unless  the  tumours  have  undergone  de- 
generative changes;  whilst  papilloma  of  the  ovary  and  tube,  dermoids 
of  the  ovary  and  malignant  disease,  are  seldom  found  without  evidence 
of  more  or  less  extensive  peritonitis. 

Severe  Septiccemia. —  When  septic  infection  of  a  severe  type  follows 
abortion,  parturition,  or  surgical  manipulations  of  the  female  genital 
organs,  instead  of  limiting  itself  to  an  attack  upon  the  mucous  lining  of 
the  genital  canal,  it  may  spread  along  the  lymphatics  and  the  veins,  and 
so  give  rise  to  a  diif use  septic  infection  of  the  pelvis,  involving,  amongst 
other  tissues,  the  peritoneum.  In  some  cases  a  peritonitis  so  produced 
remains  localised  in  the  pelvis  ;  but  much  more  frequently  the  inflamma- 
tion becomes  general,  and  an  acute  general  septic  peritonitis  is  the  result. 
Associated  with  this  condition  is  usually  found  a  diffuse  pelvic  suppura- 
tion of  a  peculiarly  malignant  form,  a  condition  already  described  in  the 
chapter  on  pelvic  cellulitis. 

Injury.  —  Both  the  teachings  of  bacteriology  and  clinical  experience 
tend  to  show  that  injury  alone  will  not  cause  peritonitis ;  and  that  it  is 
only  Avhen  the  hand  or  instrument  with  which  the  injury  is  inflicted  is 
surgically  unclean  that  the  inflammatory  process  is  excited.  In  illustra- 
tion of  this,  Ave  may  contrast  the  rarity  with  which  evil  effects  follow  the 
most  extensive  injuries  to  the  peritoneum  inflicted  during  a  difficult  and 
severe  case  of  abdominal  section  —  say  for  the  removal  of  a  tumour  in  the 
broad  ligament — or  the  accidental  perforation  of  the  unimpregnated  ute- 
rus by  the  curette  or  uterine  sound,  with  the  terrible  results  that  so  fre- 
quently follow  bungling  attempts  to  produce  criminal  abortion.  In  fatal 
cases  of  the  latter  kind  it  is  generally  foi;nd  that  death  has  resulted  from 
acute  septic  peritonitis,  with  a  punctured  wound  of  the  uterus  or  adjacent 
tissues  for  its  starting-point.  It  cannot  be  doubted  that  the  question  is 
entirely  one  of  infection.  The  operator  in  such  cases  is  almost  invariably 
found  to  have  been  either  very  ignorant  or  very  reckless,  —  in  either  case 
an  extremely  unlikely  person  to  have  adopted  precautions  against  in- 
fection. 

Allusion  has  already  been  made  to  another  way  in  which  injur}'  may 
determine  an  attack  of  pelvic  peritonitis.  The  shape  and  size  of  the 
normal  female  pelvis  are  such  as  to  fit  it  for  the  passage  of  a  normally 
sized  child  at  the  full  term,  but  are  not  such  as  to  enable  it  to  accommo- 
date anything  beyond  that.  If  therefore  the  pelvic  space  is  encroached 
upon  by  a  new  growth,  the  size  of  which  cannot  be  reduced  or  its  posi- 
tion altered  —  as,  for  example,  by  a  small  adherent  multilocular  ovarian 
tumour  —  an  obstacle  is  offered  which  either  prevents  parturition  by  the 
natural  passages  altogether,  or  renders  it  possible  only  at  the  expense  of 
much  bruising  of  the  tumour.     Should  the  latter  event  occur,  the  vitality, 


502  SYSTEM   OF  GYNAECOLOGY 

and,  with  it,  the  resisting  power  of  the  tumour  are  lowered,  so  that  it  falls 
an  easy  prey  to  pathogenetic  micro-organisms,  whether  they  attack  it 
from  the  uterus  in  front  or  the  rectum  in  the  rear.  In  this  way  the  oc- 
casional occurrence  of  puerperal  peritonitis  from  suppurative  inflamma- 
tion of  an  incarcerated  and  contused  ovarian  cyst  is  to  be  explained. 

Pelvic  Cellulitis.  —  As  pelvic  cellulitis  may  be,  and  very  frequently 
is,  secondary  to  other  forms  of  pelvic  inflammation,  so  pelvic  peritonitis 
may  be  the  result  of  the  spread  of  the  inflammatory  process  from  the 
adjacent  connective  tissue.  This  is  especially  apt  to  take  place  Avhen  the 
cellulitis  is  attended  with  suppuration,  or  when  the  portion  of  connec- 
tive tissue  chiefly  involved  is  that  which  lies  in  the  posterior  part  of 
the  pelvis. 

Pelvic  Hcematocele.  —  The  slighter  hsemorrhages  that  occur  within  the 
pelvic  peritoneum,  and  especially  those  which  take  place  from  the  open 
fimbriated  end  of  the  Fallopian  tube  in  the  early  stages  of  tubal  preg- 
nancy, usually  result  in  the  formation  of  a  pelvic  hsematocele.  The 
effused  blood  becomes  shut  off  from  the  general  peritoneal  cavity,  partly 
by  the  firm  coagulation  of  its  outer  layer,  but  chiefly  by  the  glueing  to- 
gether of  the  parts  around  it  by  adhesive  peritonitis.  In  this  way  the 
collection  of  blood  becomes  roofed  in  by  adherent  omentum  and  coils 
of  intestine,  the  peritonitis  thus  serving  to  limit  the  effusion  and  con- 
ducing to  its  ultimate  absorption. 

Disease  of  the  Appendix  Vermiformis.  —  Although  it  is  not  within 
the  scope  of  this  work  to  deal  with  diseases  other  than  those  which  are 
peculiar  to  Avomen,  no  account  of  the  etiology  of  pelvic  peritonitis  would 
be  satisfactory  that  did  not  include  some  reference  to  one  at  least  of  the 
causes  that  are  common  to  both  sexes,  namely,  disease  of  the  appendix 
vermiformis.  The  normal  position  of  the  appendix  is  in  the  iliac  fossa, 
above  the  brim  of  the  pelvis;  but  instances  are  by  no  means  uncom- 
mon in  which  the  appendix  is  found  lying  Avithin  the  pelvis,  and  it 
therefore  becomes  necessary  when  investigating  a  case  of  pelvic  perito- 
nitis, especially  if  the  right  side  be  the  part  chiefly  affected,  to  bear  in 
mind  the  possibility  that  the  inflammation  may  be  of  intestinal  origin. 
There  is  another  Avay  in  which  the  diagnosis  may.  be  obscured.  It  has 
been  shoAvn,  by  the  study  of  frozen  sections,  that  towards  the  latter  part 
of  pregnancy  the  uterine  appendages  and  broad  ligaments  are  elevated 
completely  out  of  the  true  pelvis;  the  consequence  is  that  they  are 
brought  at  that  time  into  close  contiguity  Avith  the  csecum  and  its  ap- 
pendix. If  tlie  appendix,  then,  happens  to  become  diseased,  or,  being 
already  diseased,  happens  to  set  up  an  attack  of  peritonitis  during  this 
temporary  displacement  of  parts,  the  pelvic  peritoneum,  broad  ligament, 
and  uterine  appendages  will  almost  certainly  be  involved  and  the  diffi- 
culty of  diagnosis  tliereby  greatly  increased. 

it  is  obvious  that,  within  the  limits  of  space  at  our  disposal,  it  would 
be  impossi])]e  to  funiisli  anything  like  an  exliaustive  account  of  the 
etiology  of  pelvic  jjcritonitis.  The  bacteriohtgy,  for  example,  has  of 
necessity  been  entirely  omitted.     I  hope,  however,  that  what  has  been 


PELVIC  INFLAMMATION 


503 


said  will  convey  some  idea  of  the  relative  importance  and  comparative 
frequency  of  the  principal  causes  of  pelvic  peritonitis,  and  will  serve 
to  emphasise  the  fact  that  pelvic  peritonitis  is  no  longer  to  be  regarded 
as  a  disease  in  itself,  but  as  an  indication  of  the  existence  of  some  other 
disease,  the  nature  of  Avhich  it  is  our  first  duty  at  the  bedside  to  discover. 

Pathological  Anatomy.  —  The  earliest  change  produced  in  the  perito- 
neum by  infiammation  is  hypereemia,  with  cloudy  swelling  of  the  endothe- 
lium. The  membrane  loses  its  normal  smooth,  shining  appearance,  and 
becomes  dull,  dry,  and  slightly  roughened.  Plastic  lymph  is  then  poured 
out  on  the  surface,  and  this  leads  to  the  rapid  formation  of  adhesions  be- 
tween adjacent  surfaces.  The  adhesions  thus  formed  are  the  most  charac- 
teristic feature  of  pelvic  peritonitis.  In  cases  where  the  inflammation  is 
recurrent  fresh  adhesions  take  place  during  each  attack,  so  that  there  arc 
often  in  the  same  patient  adhesions  of  different  ages  and  varying  density. 
In  addition  to  the  effusion  of  lymph  there  is  also  effusion  of  serum  :  this 
serum  tends  to  accumulate  principally  in  the  pouch  of  Douglas ;  but  it 
also  forms  collections  of  fluid  in  different  parts  of  the  pelvis,  wherever 
spaces  intervene  amongst  the  adhesions.^  Thus  are  formed  distinct  and 
limited  swellings  Avhich  often  simulate  a  true  cyst.  One  of  the  earliest 
results  of  the  adhesive  process  is  to  roof  in  the  contents  of  the  pelvis  at 
the  level  of  the  brim,  and  to  shut  off  the  cavity  of  the  pelvis  from  that  of 
the  general  peritoneum.  When  the  quantity  of  plastic  lymph  thrown 
out  is  at  all  considerable,  the  lymph  coagulates  on  the  surface  of  the 
peritoneum,  forming  a  distinct  coating  which  can  be  peeled  off  like  a 
membrane.  Lymph  coagula  are  also  formed  in  the  effused  serum,  and 
may  be  found  either  floating  in  the  fli;id  or  deposited  on  the  surrounding 
surfaces.  As  its  fluid  portion  becomes  absorbed,  this  coating  of  l^anph 
stiffens  the  j)eritoneum  and,  with  the  induration  of  the  subjacent  cellular 
tissue  due  to  secondary  cellulitis,  contributes  to  produce  the  hardness 
which  is  one  of  the  most  striking  of  the  physical  signs  of  pelvic  perito- 
nitis in  its  later  stages.  The  intraperitoneal  collections  of  serum  are 
gradually  absorbed ;  but  the  adhesions  continue  for  a  long  time,  and  many 
of  them  become  permanent,  with  the  result  of  producing  more  or  less 
serious  interference  with  the  functions  of  the  viscera  involved.  The 
evidences  of  inflammation  are  usually  most  strongly  marked  around  the 
fimbriated  end  of  the  Fallopian  tube,  and  diminish  in  intensity  as  the 
distance  from  that  point  increases.  This  is  exactly  what  our  knowledge 
of  the  etiology  of  pelvic  peritonitis  would  lead  us  to  expect.  Inasmuch 
as  the  large  majority  of  cases  of  pelvic  peritonitis  originate  in  salpingitis, 
it  is  not  surprising  that  the  firmest  adhesions  are  met  with  at  the  moutli 
of  the  tube  binding  the  fimbria  to  the  part  with  which  they  hapjiened 
at  the  time  to  be  in  contact.  Where  the  peritonitis  has  not  originated  in 
salpingitis,  but  in  some  other  morbid  condition,  such  as  a  suppurating 
ovary  or  a  diseased  appendix  vermiformis,  the  inflammation  is  most 

1  Peritonitis  attended  with  the  effusion  of  serum  has  been  quite  unnecessarily  described 
as  a  special  variety  of  pelvic  intiamniation  under  the  name  of  serous  perimetritis. 


504 


SYSTEM  OF  GYNAECOLOGY 


severe,  and  the  adhesions  are  most  dense  at  the  seat  of  origin,  wherever 
that  may  be. 

It  is  usual  for  the  Fallopian'  tube,  when  inflamed,  to  sink  below  its 
ordinary  position,  so  that  its  abdominal  ostium  lies  either  upon  the  floor 
of  the  lateral  fossa  of  the  pelvis  or  in  the  pouch  of  Douglas.  In  other 
cases  the  tube,  after  embracing  the  ovary,  becomes  adherent  by  its 
fimbriated  end  either  to  the  ovary  itself  or  to  a  part  of  the  posterior 
surface  of  the  broad  ligament  internal  to  the  ovary.  In  many  instances 
the  two  tubes  meet,  and  their  distal  ends  become  adherent  to  each  other 
behind  the  supravaginal  portion  of  the  cervix  uteri  in  the  middle  line. 
Less  frequently  the  direction  taken  by  the  tube  is  different  on  the  two 
sides:  one  tube  is  bent  upon  itself,  with  the  usual  horse-shoe  curve, 
and  terminates  behind  the  broad  ligament  or  upper  part  of  the  cervix 
uteri ;  the  other  tube  runs  at  first  sharply  forwards,  then  doubles  upon 
itself,  forming  a  loop  or  knuckle,  and  finally  runs  outwards  and 
slightly  backwards  to  terminate  against  the  lateral  Avail  of  the  pelvis, 
and  become  adherent  to  it  by  its  abdominal  opening.  In  puerperal 
cases  where,  as  has  been  already  pointed  out,  the  tube  is  lifted  out  of 
the  pelvis  by  the  development  of  the  pregnant  uterus,  the  mouth  of  the 
tube,  and  hence  the  chief  area  of  the  peritoneal  inflammation,  will  be 
found  at  or  near  the  pelvic  brim  close  to  the  border  of  the  psoas  muscle. 

Wherever  the  mouth  of  the  tube  may  be,  the  ovary  is  almost  invari- 
ably found  implicated  in  the  inflammatory  process,  and  adherent  over 
its  entire  surface  —  partly  to  the  diseased  tube,  partly  to  the  back  of  the 
broad  ligament.  In  cases  of  old  standing  it  is  very  common  to  find  the 
ovary  the  seat  of  incipient  cystic  disease,  and  considerably  enlarged. 
There  is  strong  reason  to  believe,  though  there  is  as  yet  no  definite 
proof,  that  this  condition  of  the  ovary  is  occasionally  the  result  of 
changes  induced  by  the  surrounding  peritonitis.  Whenever  the  tube 
and  ovary  are  bound  to  each  other,  the  intervening  portion  of  broad 
ligament — called  the  mesosalpinx  —  if  it  have  not  already  been  opened 
out  and  appropriated  as  part  of  the  covering  of  the  expanded  tube, 
usually  becomes  creased,  folded,  and  so  intimately  bound  up  with  the 
adhesions  as  for  all  practical  purposes  to  be  effaced. 

In  chronic  cases,  it  is  very  usual  to  find  the  peritoneum  in  the  neigh- 
bourhood of  the  adherent  mass  lifted  up  here  and  there  by  circumscribed 
coHcctions  of  serous  fluid  in  the  meshes  of  the  delicate  connective  tissue 
immediately  subjacent  to  the  peritoneum.  These  swellings  vary  in  size 
from  that  <jf  a  p(!a  to  that  of  a  large  orange.  They  are  of  no  pathological 
im  portance,  but  often  introduce  difliculties  in  the  way  of  accurate  diagnosis. 
The  mass  formed  by  the  agglutination  of  the  tube,  ovary,  and  broad 
ligament,  is  usually  found  to  have  become  adherent  posteriorly,  to  the 
peritoneum  covering  the  posterior  pelvic  wall  and  the  rectum.  Some- 
times one  or  more  coils  of  intestine  and  a  portion  of  the  omentum 
intervene  and  become  implicated  in  the  entangled  mass.  The  body  of 
the  uterus  is  sometimes  involv(;d  in  the  adhesions  and  at  other  times  is 
entirf;ly  free;  its  position  remains  normal  unless  tlu;  tube  or  ovary,  or 


PELVIC  INFLAMMATION  505 

both,  besides  being  adherent,  are  enlarged  —  the  former  by  inflamma- 
tory, the  latter  by  cystic  changes  —  when  the  uterus  is  displaced  to  the 
opposite  side  and  more  or  less  rotated  on  its  longitudinal  axis.  The 
rooting  in  of  the  pelvis  is  generally  effected  by  adhesion  of  intestine 
and  omentum  to  the  horizontal  rami  of  the  pubes  below,  to  each  other, 
and  to  the  matted  contents  of  the  pelvis  posteriorly. 

When  the  disease  causing  the  peritonitis  is  purulent  in  character  the 
peritonitis  itself  is  also  apt  to  be  purulent ;  and  instead  of  accumulations 
of  serum  amongst  the  adhesions  collections  of  pus  are  formed  —  intra- 
peritoneal abscesses.  More  rarely  general  suppurative  peritonitis  results ; 
this  only  occurs  in  septic  cases  of  exceptional  virulence,  or  from  the 
sudden  bursting  into  the  peritoneal  cavity  of  collections  of  pus  in  the 
Fallopian  tube  or  in  the  ovary.  Intraperitoneal  abscesses  may  be  single 
or  multiple,  and  may  begin  in  several  different  ways.  The  most  usual 
way  is  for  the  purulent  contents  of  a  suppurating  Fallopian  tube  to  be 
discharged  from  the  abdominal  ostium  of  the  tube  into  Douglas'  pouch 
or  into  a  space  bounded  by  adhesions.  Sometimes  both  tubes  discharge 
their  contents  into  a  common  receptacle,  and  as  the  mouth  of  the  tube  is 
usually  directed  downwards  and  backwards,  this  receptacle  is  generally 
the  pouch  of  Douglas.  Here  a  tense  fluctuating  swelling  is  formed,  easily 
felt  through  the  depressed  vaginal  roof  and  also  through  the  anterior 
rectal  wall,  which  is  bulged  backwards  so  as  to  cause  a  more  or  less 
serious  obstruction  of  that  portion  of  the  bowel.  The  discharge,  how- 
ever, may  take  place  when  the  tube  is  not  lying  with  its  mouth  in  the 
usual  direction,  as,  for  example,  when  the  salpingitis  follows  delivery, 
and  the  tube  is  situated  at  or  above  the  pelvic  brim  as  a  result  of  the 
drawing  up  of  the  parts  during  the  development  of  the  pregnant  uterus. 
The  resulting  abscess  will  then  obviously  be  formed,  not  primarily  in 
Douglas'  pouch  (though  it  may  subsequently  And  its  way  there)  but  in  a 
higher  part  of  the  pelvis, generally  in  the  neighbourhood  of  the  pelvic  brim. 

Purulent  salpingitis,  however,  not  uncommonly  results  in  the  sealing 
up  of  the  abdominal  ostium  of  the  tube;  the  pus  is  then  confined 
within  the  closed  tube,  forming  a  pyosalpinx.  Under  these  circum- 
stances an  intraperitoneal  abscess  may  be  formed  either  by  infection 
of  the  peritoneuju  through  the  walls  of  the  tube,  or  by  the  Ijursting  of 
the  pyosalpinx  from  ulceration  commencing  within,  or  by  the  spread 
of  the  infective  process  to  the  ovary,  causing  it  to  suppurate  and  to 
become  in  its  turn  a  fresh  focus  of  infection  and  the  seat  of  a  fresh 
collection  of  pus  liable  at  any  moment  to  ulcerate  and  burst. 

An  intraperitoneal  abscess,  walled  in  by  adherent  viscera,  may  either 
run  an  acute  course  or  may  remain  for  some  time  latent,  giving  few  or 
no  indications  of  its  presence.  Sooner  or  later,  however,  if  the  patient 
survive,  one  of  two  things  must  happen :  either  the  abscess  gradually 
dries  up  and  disappears  (which  there  is  good  reason  to  believe  does 
occasionally  occur  in  the  case  of  small  abscesses  with  non-virulent  con- 
tents), or  its  walls  undergo  ulceration,  and  its  contents  make  their 
escape  either  into  the  bowel  —  usually  the  rectum  or  the  sigmoid  flexure 


5o6  SYSTEM  OF  GYNECOLOGY 

of  the  colon  —  or,  more  rarely,  into  tlie  vagina,  the  bladder,  or  the  gen- 
eral cavity  of  the  periconeum  ;  or  through  some  part  of  the  abdominal 
wall.  The  common  way  of  escape  for  the  contents  of  an  intraperitoneal 
abscess  is  nndonbtedly  by  the  boAvel,  as  that  for  the  contents  of  a  cel- 
lulitic  abscess  is  through  the  abdominal  wall.  Other  routes  than  these 
may,  in  both  cases,  be  regarded  as  exceptional. 

Intraperitoneal  abscesses  in  the  pelvis  differ  from  cellulitic  abscesses 
in  the  same  part  in  another  very  important  respect.  For  whilst  the 
latter  as  a  rule  quickly  disappear  when  once  they  have  found  an  outlet, 
the  former  are  apt  to  discharge  their  contents  imperfectly,  so  that 
troublesome  sinuses  are  formed  which  for  months  and  even  for  years, 
may  remain  a  source  of  annoyance  if  not  of  serious  ill-health. 

Amongst  the  secondary  changes  that  occur  as  a  consequence  of 
these  inflammatory  processes,  there  are  one  or  two  of  such  importance 
as  to  call  for  special  mention.  When  the  salpingitis  is  unilateral,  the 
peritonitis  frequently  extends  to  the  other  side  of  the  pelvis,  involving 
the  healthy  uterine  appendages  of  that  side  in  a  mass  of  adhesions. 
Under  such  circumstances  closure  of  the  abdominal  ostium  of  the 
healthy  tube  is  apt  to  occur,  and  to  be  followed  by  the  development  of 
a  hydrosalpinx  in  the  manner  described  in  detail  by  Mr.  Doran  in  the 
article  on  "  Diseases  of  the  Fallopian  Tube."  Heematosalpinx,  as  a 
complication  of  salpingitis,  is  much  more  rare.  In  the  great  majority 
of  cases,  effusions  of  blood  within  the  tube,  and  haematoceles  of  tubal 
origin,  are  the  consequences  of  tubal  gestation ;  but  now  and  then  they 
occur  as  incidents  in  the  inflammatory  processes  above  described  quite 
independently  of  gestation. 

Symptoms.  —  An  attack  of  pelvic  peritonitis  is  characterised  by  pain 
in  the  lower  part  of  the  abdomen,  usually  sudden  in  its  onset,  and  for 
the  flrst  few  hours  severe  in  character ;  by  fever,  as  indicated  by  rise  of 
temperature  and  increased  rapidity  of  pulse,  and  very  often  by  vomiting. 
There  is  usually  more  or  less  intestinal  distension,  sometimes  general, 
.sometimes  localised.  After  the  acute  pain  has  subsided,  movement  is 
attended  with  suffering  owing  to  the  tenderness  of  the  inflamed  parts. 
The  symptoms  are  usually  sufliciently  severe  to  oblige  the  patient  to 
remain  in  bed  for  a  time;  and  the  length  of  time  that  the  patient  was 
conflned  to  bed  is  the  best  rough  test  at  our  disposal  of  the  severity  of 
a  past  attack.  Kigors  are  infrequent,  except  where  the  pelvic  peritoni- 
tis is  part  of  a  diffuse  septic  inflammation,  or  where  the  symptoms  are 
due  to  the  intraperitoneal  bursting  of  an  abscess,  as  in  the  case  of  rupt- 
ure of  a  pyosalpinx  or  a  suppurating  ovary.  Constipation  is  generally 
inet  with  ;  and  pain  preceding  defsecation  and  during  micturition  occurs 
if  tlie  inflamed  part  be  contiguous  to  the  rectum  in  the  one  case  and 
the  bladder  in  the  other. 

In  suljaciite  and  chronic  cases,  pain  in  the  l)ack  and  inability  to 
undergo  pliysieal  exertion  are  the  most  commcm  and  may  be  the  only 
symptoms.     Menstruation  usually  lx;comes  more  pi-ofuse  than  natural, 


PELVIC  INFLAMMATION  507 

and  is  often  accompanied  with  pain.  Trifling  causes,  such  as  slight 
over-exertion  or  exposure  to  cold,  readily  provoke  localised  acute  attacks 
of  inflammation  in  patients  with  chronic  pelvic  peritonitis. 

Such  recurrent  attacks  are  especially  apt  to  occur  when  the  chronic 
pelvic  peritonitis  is  kept  alive  by  the  presence  of  pelvic  suppuration. 
Indeed,  recurrent  localised  attacks  of  peritonitis  afford  a  much  more 
valuable  guide  to  the  diagnosis  of  pus  in  the  pelvis  than  does  the 
temperature.  In  twelve  out  of  thirty  of  my  own  operation  cases  in 
which  suppuration  was  present,  the  temperature  before  oijeration  was 
absolutely  normal ;  and  in  only  twelve  of  the  remainder  was  the 
temperature  distinctly  and  persistently  febrile. 

In  severe  cases,  however,  attended  with  suppuration,  patients  become 
ill  and  emaciated,  and  entirely  incapacitated  for  work  or  for  exertion  of 
any  kind.  In  the  worst  cases  of  all  the  patient  becomes  a  bedridden 
invalid.  Between  the  two  extremes,  the  one  patient  who  is  wholly  confined 
to  bed  and  the  other  who  is  scarcely  conscious  of  an^-thing  wrong  except 
during  the  occasional  acute  attacks  that  serve  to  betray  the  existence  of 
some  deep-seated  lesion,  there  are,  of  coiirse,  all  possible  gradations.  The 
amount  of  suffering  endured  by  a  patient  with  chronic  inflammatory 
disease  of  the  uterine  appendages  must  always  largely  depend,  not  only 
on  the  extent  and  nature  of  the  disease,  but  also  upon  the  class  of  life  to 
which  she  belongs,  and  the  demands  made  upon  her  activity. 

During  an  acute  attack  of  pelvic  peritonitis,  the  patient  lies  on 
her  back  and  is  least  uncomfortable  when  the  knees  are  drawn  up. 
There  is  extreme  tenderness  to  the  touch  over  the  lower  part  of  the 
abdomen,  with  rigidity  of  the  abdominal  wall  over  the  affected  parts. 
This  rigidity  is  due  to  contraction  of  the  muscles,  and  is  not  under  the 
control  of  the  patient's  will.  In  exceptional  cases  a  definite  swelling- 
can  be  detected  on  abdominal  palpation.  This  is  the  case  when  the 
inflamed  appendages  happen  to  be  situated  above  the  pelvic  brim;  or 
when  the  attack  is  due  to  sui)puration  in  an  ovarian  cyst  of  sufiiciently 
large  size  to  be  reached  on  abdominal  examination ;  or  when  there  is 
an  encysted  exudation  of  serum  or  of  pus  in  front  of  the  uterus,  or  a 
sufficiently  extensive  exudation  posteriorly  to  push  the  uterus  forwards 
against  the  abdominal  wall.  As  a  rule,  however,  there  is  no  swelling  to  be 
discovered,  and  any  noticeable  enlargement  is  merely  that  produced  by 
local  distension  of  the  intestine  with  flatus.  On  vaginal  examination  the 
parts  will,  at  this  stage,  be  too  sensitive  to  permit  a  satisfactory  investiga- 
tion of  the  lateral  regions  of  the  pelvis.  If  there  be  any  depression  of  the 
vaginal  roof,  it  will  be  not  lateral,  but  central ;  and  will  be  due  to  an 
encysted  effusion  of  fluid,  serous  or  purulent,  in  the  pouch  of  Douglas, 
distending  the  sac,  obliterating  the  posterior  vaginal  fornix, and  displacing 
the  uterus  forwards.  There  may  be  tenderness  and  a  sense  of  resistance 
on  pressing  the  fingers  upwards  into  one  or  both  lateral  fornices ;  but, 
unless  there  be  a  cystic  ovary  or  other  cause  of  imusual  enlargement  on 
the  affected  side,  it  will  not  be  possible  to  map  out  any  definite  swelling 
in  the  posterior  fossw  of  the  pelvis  until  the  acute  symptoms  have 


5o8  S YSTEM  OF  G YN^ COLOG  Y 

subsided.  When  this  event  has  occurred,  a  careful  bimanual  examination, 
conducted  if  possible  while  the  patient  is  under  the  influence  of  an 
aneesthetic",  will  reveal  in  the  posterior  fossa  of  the  pelvis  on  one  or  both 
sides  of  the  uterus  the  presence  of  a  fixed,  irregular,  tender  swelling. 
This  begins  at  the  uterine  cornu  as  a  cylindrical  body  about  equal  in 
thickness  to  a  lead  pencil,  and  is  capable  of  being  rolled  between  the 
fingers ;  it  runs  outwards  for  a  short  distance,  and  then  becomes  some- 
what suddenh'  thicker,  curves  upon  itself,  completely  reversing  its  direc- 
tion, and  finally  ends  behind  the  cervix  uteri  in  the  pouch  of  Douglas. 
This  swelling  consists  of  the  thickened  Fallopian  tube,  adherent  to  the 
ovary,  embracing  it  in  the  concavity  of  its  curve,  and  surrounded  on 
all  sides  by  thickened  and  adherent  peritoneum.  The  uterus  is  seldom 
pushed  aside  by  this  mass,  and  does  not,  as  in  the  case  of  cellulitis  of  the 
broad  ligament,  appear  to  form  a  part  of  it.  The  uterus  may,  however, 
have  been  retroverted  or  retroflexed  to  begin  with,  when  it  will  have 
become  adherent  in  its  abnormal  position ;  or  it  may  be  pushed  forwards 
as  a  whole  by  an  effusion  of  serum  or  pus  in  the  pouch  of  Douglas. 
Lateral  displacement  only  occurs  when  there  is  either  exceptional  en- 
largement of  the  diseased  tube  or  of  the  ovary.  Under  these  circum- 
stances, in  addition  to  the  pushing  over  of  the  litems  towards  the 
opposite  side,  there  may  be  some  bulging  of  the  swelling  into  the  vagina, 
causing  a  depression  of  the  lateral  fornix ;  a  condition  which,  generally 
speaking,  is  much  more  characteristic  of  pelvic  cellulitis  than  of  pelvic 
peritonitis.  When  the  lateral  swelling  in  the  latter  affection  is  large 
enough  to  produce  these  displacements,  the  cause  will,  in  the  majority  of 
cases,  be  found  to  be  enlargement  of  the  ovary  from  cystic  disease ;  a  not 
very  uncommon  complication  of  inflammation  of  the  uterine  appendages. 
The  shape  and  consistence  of  the  lateral  swelling  vary  considerably  in 
different  cases, and  eveninthe  different  stagesof  the  same  case.  Sometimes 
the  tube  is  soft  and  sausage  shaped ;  this  is  specially  apt  to  be  the  case 
when  the  abdominal  ostium  is  occluded  and  the  tube  is  uniformly  dis- 
tended. Sometimes  the  distension  affects  the  outer  end  only,  giving  the 
mass  the  shape  of  a  retort.  In  other  cases  the  tube  becomes  irregularly 
distended  from  sacculation,  or  is  thrown  into  complicated  folds,  forming 
sharp  knuckles  or  prominences  here  and  there  as  it  bends  upon  itself, 
and  presenting  to  the  examining  finger  sausage-like  convolutions  with 
intervening  grooves.  The  consistence  of  the  mass  depends  partly  upon 
the  extent  to  which  the  walls  of  the  tube  have  become  thickened,  and 
partly  upon  the  amount  of  induration  of  the  surrounding  peritoneum. 
This  latter  is  found  to  be  most  marked  when  the  examination  is  made 
soon  after  an  acute  attack.  As  the  ])atient  recovers  from  the  immediate 
effects  of  such  an  attack,  the  hardness  of  the  peritoneum  gradually 
diminishes,  and  the  outlines  of  the  adherent  appendages  beconui  more 
easily  defined.  In  cases  attended  with  su])[)uration  or  complicated  with 
effusions  of  serum  oi'  pus  amongst  the  peritoneal  adhesions,  the  swelling 
is  rendered  still  more  irregular  in  shape  and  unequal  in  consistence. 
In  some  parts  it  may  be  possible  to  obtain  clear  evidence  of  fluctuation. 


PELVIC  INFLAMMATION  509 

Diagnosis.  —  The  only  conditions  likely  to  be  mistaken  for  pelvic 
peritonitis  are  pelvic  cellulitis  and  pelvic  haematocele. 

Pelvic  Cellulitis.  —  Some  help  in  the  diagnosis  from  cellulitis  may 
be  obtained  from  the  etiology  of  the  two  affections.  Pelvic  cellulitis  is, 
to  begin  with,  a  much  rarer  disease  than  pelvic  peritonitis :  its  origin  is 
exclusively  septic,  never  gonorrhoeal  or  tubercular ;  it  is  essentially  a 
disease  of  the  puerperium,  due  to  absorption  of  septic  matter  through 
wounds  of  the  cervix  uteri  and  vagina  occasioned  during  the  process  of 
parturition.  Over-stretching  and  laceration  of  the  cervix  being  likely 
to  occur  only  when  the  child  is  of  full  size,  it  is  rare  to  find  pelvic 
cellulitis  following  abortion  and  premature  labour.  In  the  cases  where 
pelvic  inflammation  is  the  result  of  the  absorption  of  septic  matter 
during  surgical  manipulations,  it  will  be  found  that  it  only  takes  the  form 
of  cellulitis  where  the  manipulations  have  involved  the  integrity  of  the 
cervical  tissues.  Where  the  manipulations  have  been  intra-uterine  and 
unattended  with  injury  to  the  cervix,  the  poison  is  absorbed  not  by 
the  connective  tissue,  but  by  the  endometrium,  the  resulting  inflamma- 
tion extending  along  the  mucous  membrane  of  the  Fallopian  tube  to  the 
peritoneum. 

It  IS  generally  held,  and  with  truth,  that  the  presence  of  acute  pain 
points  to  the  pelvic  inflammation  being  peritoneal.  Cellulitis,  when  un- 
complicated, is  a  disease  unattended  with  pain,  or  at  any  rate  with  severe 
pain.  The  sudden  onset,  then,  of  acute  pain  in  an  attack  of  pelvic  in- 
flammation is  an  indication  that  the  inflammation  has  reached  the  peri- 
toneum. After  the  acute  stage  has  passed,  however,  the  pain  of  pelvic 
peritonitis  is  only  felt  in  standing  or  walking,  though  the  tenderness 
remains,  and  is  apparent  on  vaginal  examination  and  on  coitus. 

It  must,  nevertheless,  be  remembered  that  pain  in  the  pelvis,  as  else- 
where, is  a  most  misleading  symptom,  and  is  seldom  as  severe  in  cases 
of  actual  disease  as  it  is  in  many  neurotic  conditions  in  which  there  is 
no  obvious  lesion,  inflammatory  or  other. 

In  both  cellulitis  and  peritonitis  there  may  be  and  generally  is  a 
swelling  in  the  lateral  regions  of  the  pelvis ;  but,  whereas  in  cellulitis  the 
swelling  is  usually  unilateral,  smooth,  uniform,  attended  with  depression 
and  fixation  of  the  vaginal  roof,  and  of  stony  hardness,  in  peritonitis  it 
is  more  often  bilateral  than  unilateral,  and  instead  of  being  smooth  and 
of  uniform  consistence,  and  conveying  the  impression  of  being  due  to  an 
exudation  in  the  tissues  immediately  subjacent  to  the  vaginal  wall,  it  is 
irregular  in  outline,  unequal  in  consistence,  and  is  ascertained  on  bimanual 
examination  to  be  situated  in  the  fossa  behind  the  broad  ligament  with  a 
certain  thickness  of  normal  tissue  intervening  between  it  and  the  examin- 
ing finger.  Another  point  of  distinction  is  that  in  cellulitis  the  cervix 
uteri  is  apt  to  be  surrounded  by  a  hard,  thick  collar  in  which  it  is  im- 
movably set;  whilst  in  peritonitis  there  is  no  such  girdle  of  indurated 
tissue,  and  the  impairment  of  the  mobility  of  the  cervix  is  never  so  com- 
plete. Further,  in  cellulitis  there  is  no  inflammatory  effusion  or  any 
kind  of  swelling  in  Douglas'  pouch ;    whereas  in  peritonitis  there  is 


SYSTEM   OF  GYNMCOLOGY 


almost  always  either  a  certain  amount  of  distension  from  inflammatory 
effusion  (serous  or  purulent),  or  the  pouch  is  felt  to  be  occupied  by  a 
hard,  irregular,  fixed  swelling,  adherent  to  the  supravaginal  portion  of 
the  cervix  uteri,  and  continuous  with  the  fixed  irregidar  mass  situated 
in  one  or  both  lateral  fossae. 

A  similar  difference  exists  in  the  conditions  found  on  rectal  examina- 
tion. In  cellulitis  the  rectum  will  often  be  felt  to  be  surrounded,  wholly 
or  partially,  by  a  belt  of  exudation  of  stony  hardness,  fixing  the  coats  of 
the  bowel  at  that  part  and  narrowing  the  calibre  of  the  canal.  In  peri- 
tonitis, on  the  other  hand,  any  effusion  within  reach  from  the  rectum 
Avill  be  in  Douglas'  pouch  ;  it  will  be  less  hard,  it  will  not  affect  the 
mobility  of  the  coats  of  the  bowel  to  the  same  extent,  and,  though  it  may 
press  on  the  bowel  in  front,  it  will  not  encroach  upon  it  laterally. 

When  the  broad  ligament  itself  is  the  seat  of  a  cellulitic  exudation, 
bimanual  examination  will  reveal  a  hard,  smooth,  flattened  tumour  by 
the  side  of  and  continuous  with  the  uterus,  and  sometimes  displacing 
it  slightly  to  the  opposite  side.  This  tumour  can  be  moved  backwards 
and  forwards  within  certain  narrow  limits.  The  swelling  caused  by  the 
inflamed  and  adherent  appendages  in  pelvic  peritonitis  is,  on  the  contrary, 
of  irregular  contour,  and  is  not  continuous  with  the  uterus,  but  on  a 
plane  behind  it,  and  is  quite  fixed. 

When  the  cellulitic  exudation  has  reached  the  sub-peritoneal  connec- 
tive tissue  of  the  anterior  abdominal  wall,  it  gives  rise  to  a  smooth,  hard 
swelling  in  the  deeper  layers  of  the  wall  itself,  either  immediately  above 
Poupart's  ligament,  or,  more  rarely,  in  the  suprapubic  region.  This 
swelling  has  a  well-defined  upper  boundary  and  is  quite  characteristic, 
there  being  nothing  in  the  least  like  it  in  pelvic  peritonitis. 

In  non-suppurative  cellulitis  the  exudation  becomes  entirely  absorbed, 
and  the  hardness  disappears  without  leaving  any  trace,  except  where  the 
exudation  is  in  the  substance  of  the  broad  ligament,  when  there  may  be 
some  contraction  with  more  or  less  dragging  over  of  the  uterus  to  the 
affected  side.  In  favourable  cases  of  peritonitis  the  hardness  and  thick- 
ening become  much  less  marked;  but  the  viscera  once  adherent  are  apt 
to  remain  so  for  an  indefinite  time,  and  there  is  generally  to  be  felt  a 
soft,  irregular  mass  in  the  posterior  part  of  the  pelvis  for  the  remainder 
of  the  patient's  life,  with  some  amount  of  uterine  fixation  and  possibly 
of  displacement. 

Finally,  su}>puratif)n  in  pelvic  cellulitis  generally  takes  the  form  of 
an  abscess  pointing  on  the  surface  of  the  abdominal  wall  a  little  above 
Poupart's  ligament,  and  quickly  disappearing  wlien  once  it  has  found  an 
outlet ;  whereas  in  pelvic  peritonitis,  if  suppuration  exist,  it  is  either  in 
the  Fallopian  tube  (pyosalpinx),  or  in  the  ovary,  or  amongst  the  peri- 
toneal adhesions  (intraperitoneal  abscess) :  its  favourite  outlet  is  into 
the  large  bowel  or  some  other  internal  i)art,  and  it  is  apt  to  lead  to  the 
establishment  of  troublesome  sinuses. 

I'clvic  I[(nm(Unc/d(>.  —  The  diagnosis  of  an  effusion  of  blood  in  the 
p'tufli  of  Douglas  from  effusions  of  serum  or  pus  depends  largely  upon  the 


PELVIC  INFLAMMATION  511 

clinical  history  of  the  case,  and  upon  the  transient  character  of  the  febrile 
disturbance  in  pelvic  haematocele.  As  pelvic  haematocele,  in  the  vast 
majority  of  cases,  is  a  complication  of  tubal  pregnancy,  there  will  usually 
be  a  history  of  one  or  two  menstrual  periods  having  been  passed,  and  of 
a  sudden  attack  of  pain,  accompanied  with  nausea  or  vomiting  and  an 
alarming  feeling  of  faintness.  The  patient  will  have  a  blanched  appear- 
ance, the  pallor  being  greater  than  the  slight  uterine  haemorrhage  usually 
present  is  sufficient  to  account  for.  The  effusion,  at  first  distinctly  fluid, 
soon  acquires  a  doughy  consistence  from  partial  clotting ;  and,  later,  be- 
comes diminished  in  bulk  and  harder,  as  the  peripheral  portion  of  the 
effused  blood  forms  a  dense  fibrinous  wall.  The  possibility,  however, 
of  the  hsematocele  undergoing  suppuration  must  not  be  lost  sight  of.  The 
signs  and  symptoms  in  such  an  event  will  be  similar  to  those  of  an  intra- 
peritoneal abscess  with  septicaemia. 

Prognosis The  prognosis  in  pelvic  peritonitis  is  much  less  favour- 
able than  in  pelvic  cellulitis.  Not  only  is  the  mortality  higher,  but  the 
after-effects,  in  those  patients  who  recover,  are  apt  to  be  much  more 
troublesome,  and  are  not  unfrequently  of  a  character  sufficiently  serious 
to  entail  a  life  of  chronic  invalidism.  The  disease  which  caused  the 
peritonitis  still  remains  when  the  acute  attack  of  peritoneal  inflammation 
has  subsided,  and  constitutes  a  centre  around  which  fresh  attacks  of 
inflammation  are  continually  liable  to  occur,  either  from  changes  in  the 
diseased  tissues  themselves,  or  from  external  agencies  (such  as  exposure  to 
cold  and  damp)  of  a  nature  insufficient  to  excite  inflammation  in  healthy 
tissues,  but  capable  of  doing  so  only  too  readily  when  the  power  of  re- 
sistance of  the  tissues  is  lowered  by  disease. 

The  tendency  to  recurrent  attacks  of  peritonitis  is  more  marked  in 
cases  where  the  underlying  disease  is  accompanied  by  pus  either  in  the 
form  of  pyosalpinx,  suppurating  ovary,  or  intraperitoneal  abscess. 

The  damage  done  to  the  uterus,  ovaries,  and  Fallopian  tubes  during 
an  attack  of  pelvic  peritonitis,  especially  that  done  to  the  tube  by  the 
closure,  adhesion,  or  displacement  of  its  abdominal  ostium,  frequently  has 
the  effect  of  producing  sterility ;  and  even  if  the  gradual  absorption  of 
morbid  adhesions  permit  the  occurrence  of  conception,  the  continuance 
of  gestation  to  full  term  may  be  rendered  impossible  owing  to  inter- 
ference with  the  normal  expansion  of  the  pregnant  uterus.  It  is  not 
possible,  however,  in  any  given  case  to  be  certain  that  pregnancy  cannot 
thenceforth  occur;  for  experience  shows  that,  even  after  the  most  violent 
peritonitis,  the  parts  may  recover  themselves  sufficiently  to  permit  not 
only  of  subsequent  conception,  but  of  normal  delivery  at  term.  The 
discreet  practitioner,  therefore,  will  always  hesitate  to  commit  himself 
to  the  opinion  that  his  patient  cannot  again  bear  children. 

Another  not  infrequent  effect  of  pelvic  ])eritonitis  is  permanent  inter- 
ference with  the  normal  action  of  the  bowels  due  to  the  implication  of 
intestine  in  the  pelvic  adhesions.  Occasionally  still  more  serious  resulte 
follow  these  adhesions  in  the  form  of  acute  intestinal  obstruction. 


SYSTEM  OF  GYNECOLOGY 


It  must  be  remembered,  nevertheless,  that  pelvic  peritonitis  may  result 
in  complete  recovery,  and  that  the  prognosis  must  be  determined  by  the 
special  circumstances  of  each  individual  case. 

Treatment.  —  1.  Preventive.  —  Inasmuch  as  in  the  large  majority  of 
non-puerperal  cases,  pelvic  peritonitis  is  due  to  gonorrhceal  salpingitis,  the 
prophylactic  treatment  consists  in  destroying  the  gonorrhceal  infection 
before  it  has  extended  to  parts  beyond  the  reach  of  local  applications. 
Gonorrhoea  in  the  woman  is  still  regarded  in  this  country  as  a  compara- 
tively unimportant  affection,  though  it  probably  destroys  the  health  of  a 
larger  number  of  women  than  does  even  the  much  more  dreaded  poison 
of  syphilis.  As  a  rule,  the  earlier  indications  of  the  disease  pass  unre- 
garded :  they  are  attended  with  but  little  pain,  often  with  none  when  the 
urethra  is  not  involved,  and  the  significance  of  the  purulent  discharge  is  not 
realised.  Hence  it  frequently  happens  that  medical  advice  is  not  sought 
until  the  infection  has  had  time  to  inflict  serious,  and  sometimes  life-long 
damage  on  important  organs.  And  even  if  advice  be  obtained  earlier, 
the  disease  is  not  always  regarded  seriously  or  vigorous  treatment 
adopted.  It  does  not  come  within  the  scope  of  this  article  to  describe 
the  symptoms  and  treatment  of  acute  gonorrhoea  in  the  female.  It  must 
suffice  to  point  out  that  a  latent  gonorrhoea  in  the  male,  supposed  to 
have  been  cured,  may  be  roused  by  marriage  into  renewed  activity ;  and 
that  a  purulent  vaginal  discharge,  especially  if  in  a  recently  married 
woman,  should  always  be  looked  upon  with  grave  suspicion,  and  its 
treatment  undertaken  with  a  due  sense  of  responsibility. 

The  preventive  treatment  of  pelvic  peritonitis  due  to  septic  salpingitis 
—  which  includes  (1)  nearly  all  the  non-puerperal  cases  that  are  not 
accounted  for  by  gonorrhoea,  and  (2)  all  the  cases  that  are  traceable  to 
abortion,  parturition,  and  surgical  manipulation  —  consists  in  a  rigid 
adherence  to  the  rules  of  aseptic  surgery  and  midwifery,  especially  as  re- 
gards the  thorough  and  even  elaborate  disinfection  of  hands,  instruments, 
and  sponges.  By  this  means  only  can  we  hope,  in  the  midst  of  our  varied 
work,  to  avoid  becoming  the  occasional  carriers  of  septic  infection. 

In  those  who  have  once  been  the  subject  of  pelvic  peritonitis,  it  be- 
comes important  to  avoid  such  causes  as  are  likely  to  provoke  a  relapse. 
The  utmost  care,  for  example,  should  be  exercised  to  avoid  exposure  to 
cold  and  damp,  especially  during  the  menstrual  period ;  and  over-exertion 
should  at  all  times  be  guarded  against.  Prolonged  standing  appears  to 
be  attended  witli  consequences  quite  as  disastrous  as  excessive  exercise, 
and  should  therefore  be  avoided  witli  equal  determination.  It  is  not 
often  necessary  for  patients  in  whom,  notwitlistanding  the  existence  of 
chronic  inflammatory  disease  of  the  uterine  appendages,  there  is  no  active 
peritonitis  present,  to  be  condemned  to  lie  in  bed  and  lead  an  invalid's 
life ;  but  it  is  nevertheless  essential  to  insist  upon  their  observance  during 
each  day  of  definite  periods  of  rest  in  the  recumbent  posture.  It  will 
greatly  conduce  to  the  formation  of  regular  habits  of  this  kind  for  the 
medical  attendant  to  draw  up  a  few  simple  but  definite  rules  for  his 


PELVIC  INFLAMMATION  513 

patient's  guidance,  and  strongly  insist  on  their  being  diligently  carried 
out.  Scarcely  less  important  than  the  rigorous  avoidance  of  over-fatigue, 
is  the  need  for  constant  attention  to  the  state  of  the  bowels.  Intestinal 
adhesions  have  the  almost  invariable  effect  of  producing  habitual  consti- 
pation with  a  tendency  to  faecal  accumulation,  a  condition  highly  favour- 
able to  the  development  and  migration  through  the  coats  of  the  bowel 
of  pathogenetic  micro-organisms.  Hence  no  effort  should  be  spared,  by 
means  of  suitable  aperients,  supplemented,  if  necessary,  by  enemata  of 
glycerine  or  soap  and  water,  to  overcome  in  these  patients  any  tendency 
to  intestinal  inaction,  and  to  ensure  a  thorough  emptying  of  the  larger 
bowel  every  day. 

2.  Medical.  —  The  medical  treatment  of  pelvic  peritonitis  consists  in 
very  much  the  same  measures  as  those  recommended  for  the  relief  of 
pelvic  cellulitis,  with  the  important  difference,  that  whereas  opium  and 
its  derivatives  are  never  needed  in  uncomplicated  cellulitis,  they  may  be 
necessary  in  pelvic  peritonitis  in  order  to  relieve  the  acute  pain.  Even 
then,  however,  their  administration  should  be  regarded  as  an  unavoidable 
evil,  and  should  be  discontinued  at  the  earliest  possible  moment.  The 
constipating  effects  of  the  opium  or  morphia  should  be  promptly  obviated, 
all  prejudices  to  the  contrary  notwithstanding,  by  efficient  aperients  or 
enemata,  or  both.  The  accumulation  of  scybala  is  much  inore  powerful 
for  harm  than  the  action  of  purgative  medicine,  and  there  should  be  no 
hesitation  as  to  the  choice  of  the  lesser  evil. 

Rest  in  bed  is,  of  course,  essential  during  an  acute  attack.  The  diet 
should  be  restricted,  if  not  to  liquid  food,  at  any  rate  to  food  of  the 
simplest  and  most  digestible  character,  which  should  be  taken  at  regular 
intervals  so  as  to  allow  adequate  time  for  digestion.  Pain  should  be 
relieved  by  the  application  of  hot  flannel  fomentations,  and  distension 
by  enemata.  Should  the  patient  be  tormented  with  thirst  the  frequent 
sipping  of  hot  (not  lukewarm)  water  will  do  more  to  alleviate  it  than 
either  the  continual  sucking  of  ice  or  the  drinking  of  effervescing  waters. 
There  is  no  reason  for  withholding  an  occasional  draught  of  cold  water 
if  the  patient  long  for  it.  If  an  enema  fail  to  afford  adequate  relief  to 
the  bowels  there  need  be  no  hesitation  in  administering  a  full  dose  of 
castor  oil  (the  best  of  all  aperients  for  the  purpose  if  it  can  be  retained ). 
calomel,  or  magnesium  sulphate. 

The  state  of  the  pulse,  which  in  peritonitis  is  ordinarily  a  much  truer 
guide  to  the  condition  of  the  patient  than  the  temperature,  will  iiulicate 
when  stimulants  are  needed.  If  the  pulse  show  signs  of  flagging —  that 
is  of  becoming  thin,  feeble,  and  intermittent  —  brand}-  or  whisky  should 
be  given  in  defined  and  measured  doses  diluted  with  five  or  six  times 
the  quantity  of  water,  and  the  effect  carefully  Avatched  with  a  view  to 
the  increase  or  diminution  of  the  dose  as  may  be  required.  Stiuiulants 
should  not  be  allowed,  however,  to  take  the  place  of  food,  but  should  be 
given  as  far  as  possible  with  food.  Any  tendency  to  collapse,  indicated 
by  coldness  of  the  extremities,  sunken  features,  flickering  ]n\lse,  and  sub- 
normal temperature,  should  be  further  combated  bv  the  ajiplication  of 

2l 


514  SyST£J/   OF  GYN.-ECOLOGY 

hot  "water  bottles  and  the  subcutaneous  injection  of  stiychnia.  Of  still 
greater  importance  is  it  to  bear  in  mind  the  intensely  depressing  effect 
of  intestinal  distension,  and  to  adopt  means  for  enabling  the  patient  from 
time  to  time  to  expel  accumulated  flatus.  Nothing  answers  the  purpose 
so  well  as  small  soap-and- water  clysters,  which,  if  necessary,  may  be  fre- 
quently repeated.  The  introduction  of  a  soft  india-rubber  rectal  tube  is 
also  often  of  great  service ;  the  tube  may  be  left  in  for  a  quarter  of  an  hour 
at  a  time  if  its  presence  is  not  a  serious  annoyance  to  the  patient.  Turn- 
ing the  patient  on  to  her  side  is  another,  sometimes  singularly  effectual, 
means  of  assisting  in  the  passage  of  flatus. 

Surgical.  —  Surgical  measures  are  not  often  called  for  during  an  acute 
attack  of  pelvic  peritonitis.  When,  however,  Douglas'  pouch  is  tense  from 
fluid  distension,  forming  a  swelling  more  or  less  globular  in  shape,  and  en- 
croaching both  on  the  vagina  and  rectum,  there  can  be  no  hesitation  as 
to  the  propriety  of  making  an  opening  through  the  vaginal  roof.  Even 
should  the  inflammatory  effusion  prove  to  be  serous  only,  the  mere  removal 
of  tension  will  give  great  relief.  If,  on  the  other  hand,  the  swelling  prove 
to  have  been  an  intraperitoneal  abscess,  such  timely  interference  will 
not  only  afford  immediate  relief  to  the  more  urgent  symptoms,  but  will 
prevent  the  bursting  of  the  abscess  into  the  rectum,  with  the  possible 
results  of  incomplete  evacuation  and  the  establishment  of  a  troublesome 
sinus. 

With  this  exception  it  is  usually  wise  to  defer  surgical  intervention 
until  the  acute  symptoms  have  subsided,  and  until  an  opportunity  has 
been  afforded  of  making  a  thorough  bimanual  examination,  and  of  arriving 
at  as  near  an  approach  to  a  correct  diagnosis  as  the  circumstances  of  the 
case  permit.  If  the  attack  is  the  first  the  patient  has  had,  and  if  the 
swelling,  usually  to  be  found  in  one  or  both  posterior  quadrants  of  the 
pelvis,  be  of  so  moderate  a  size  as  not  to  be  incompatible  with  the  existence 
of  a  non-purulent  inflammation  of  the  uterine  appendages,  the  case  is 
obviously  not  one  in  which  operative  interference  should,  for  the  moment 
at  any  rate,  be  recommended.  If,  on  the  other  hand,  the  patient  have 
had  similar  attacks  previously,  and  if  the  swelling  have  attained  such 
dimensions  as  to  make  it  fairly  certain  that  in  the  midst  of  it  there  is 
either  an  occluded  and  distended  Fallopian  tube  or  an  ovary  enlarged  by 
cystic  growth,  the  indications  for  the  removal  of  the  disease  are  perfectly 
clear.  Such  a  mass,  with  a  history  of  recurrent  attacks  of  peritonitis, 
almost  invariably  means  the  presence  of  pus;  and  where  pus  is  there 
is  no  remedy  wortliy  of  the  name  except  such  as  is  offered  by  surgery. 
Between  these  two  extreme  instances  there  are,  of  course,  cases  present- 
ing all  gradations ;  and  it  is  impossible  to  lay  down  detailed  rules  as  to 
the  conditions  that  justify  operative  measures  and  those  that  do  not. 
Every  case  must  1)0  (hicided  on  its  own  merits,  and  according  to  the  class 
of  life  to  which  the  jjatient  belongs.  A  woman  from  the  lal)0uring  class 
cannot  afford  to  spend  several  months  of  hor  life  as  an  invalid,  if  there 
be  a  (juickcr  way  to  I'ocovery  ;  whereas  one  wlio,  with  am])le  means,  has 
no  necessity  for  leading  an  active^  life,  will  be  perfectly  justified  in  not 


PELVIC  INFLAMMATION  515 

submitting  to  operation  until    treatment  by  prolonged    rest  has  been 
thoroughly  carried  out  and  has  failed  to  effect  a  cure. 

When  operation  has  been  decided  upon,  the  method  of  operating  still 
remains  to  be  determined.  Abdominal  section,  being  the  older  and  more 
generally  adopted  method,  will  be  first  described.  An  aperient  having 
been  administered  on  the  previous  day,  and  an  enema  early  in  the  morning 
of  the  day  of  operation,  and  the  skin  of  the  abdominal  wall  having  Vjeen 
thoroughly  disinfectedin  the  manner  usual  before  all  abdominal  operations, 
the  patient  is  placed  on  the  operating  table  either  in  the  ordinary  or  in 
the  Trendelenburg  position  (the  latter  affording  the  operator  a  better 
view  of  the  pelvic  contents),  and  an  incision  from  1\  in.  to  3  in.  long  is 
made  in  the  middle  line,  ending  about  an  inch  above  the  summit  of  the 
symphysis  pubis.  The  operator  must  be  alive  to  the  possibility  of  adhe- 
sions between  the  intestine  and  the  under  surface  of  the  anterior  abdominal 
wall,  and  he  must  proceed  carefully  as  he  approaches  the  peritoneal  cavity. 
Usually,  on  opening  the  cavity,  the  omentum  is  found  drawn  down  so  as 
to  cover  in  the  contents  of  the  pelvis  anteriorly,  and  to  have  contracted 
adhesions  to  the  peritoneum  as  it  becomes  reflected  on  the  anterior  abdom- 
inal wall,  as  well  as  on  the  uterus  and  other  pelvic  viscera.  The  first 
step  is  to  separate  these  adhesions  sufficiently  to  allow  the  omentum  (and 
any  coils  of  small  intestine  which  ma}^  have  become  adherent  to  it)  to  be 
drawn  upwards,  or  to  one  side,  so  as  to  expose  the  matted  contents  of  the 
pelvisbehindit.  Guidedchiefly,if  not  indeed  entirely,  by  the  sense  of  touch 
(unless  the  patient  be  in  the  Trendelenburg  posture,  when  he  may  be  aided 
in  his  manipulations  by  the  sense  of  sight),  the  operator  now  endeavours, 
with  the  tips  of  the  first  two  fingers  of  his  left  hand,  to  enucleate  the 
diseased  uterine  appendages  from  their  adlierent  surroundings.  His  first 
landmark  is  the  body  of  the  uterus,  which  is  sometimes  free  and  some- 
times implicated  in  the  adherent  mass.  In  the  latter  case  identification 
may  be  difficult,  and  it  may  be  necessary  for  an  assistant  to  pass  one  or  two 
fingers  into  the  vagina  and  to  elevate  the  uterus  by  pressure  on  the  cervix. 
When  the  fundus  uteri  has  thus  been  identified,  the  Fallopian  tube  (on 
the  diseased  side  if  only  one  side  is  affected)  is  to  be  traced  outwards 
from  the  uterine  cornu,  and  made  to  serve  as  a  guide  in  searching  for  the 
planes  of  adhesion.  If  the  Fallopian  tube,  which  is  often  normal  in  size 
and  consistence  for  the  first  inch  or  so,  turns  quickh*  backwards  and 
becomes  lost  in  the  adherent  mass,  the  safest  way  of  commencing  the 
separation  of  adhesions  is  by  keeping  the  fingers  close  to  the  posterior 
surface  of  the  \iterus,  and  tracing  the  adherent  mass  downwards  into 
Douglas'  pouch.  During  the  manipulations  necessary  in  separating  the 
mass  from  the  walls  of  the  pouch,  including  the  anterior  wall  of  the  rec- 
tum, it  is  often  desirable  for  an  assistant  to  pass  a  forefinger  into  the 
rectum ;  partly  to  facilitate  the  separation  by  steadying  the  bowel,  and 
partly  to  enable  the  operator  to  know  exactly  where  the  bowel  is  and 
when  he  is  in  dangerous  proximity  to  it.  The  separation  of  adhesions  in 
Douglas'  pouch  is  very  often  the  most  difficult  part  of  the  operation. 
When  this  has  been  effected  the  tips  of  the  fingers  are  to  be  insinuated 


5i6  SYSTEM   OF  GYNECOLOGY 

beneath,  the  mass,  and  the  separation  is  to  be  continued  posteriorly  from 
below  upwards.  When  the  mass  has  been  cleared  from  its  posterior  and 
inferior  attachments  to  the  uterus  and  to  the  uterine  appendages  of  the 
opposite  side,  there  still  remain  the  adhesions  to  the  back  of  the  broad 
ligament  which  has  usually  become  more  or  less  so  folded  over  the  dis- 
eased parts  as  to  form  a  deeply  concave  surface  on  what  is,  anatomically, 
its  posterior  aspect.  It  is  from  this  concave  surface  that  the  mass  has 
now  to  be  separated  in  order  to  allow  of  its  being  brought  up  into  view, 
and  to  permit  of  the  transfixion  of  the  broad  ligament  below  it.  The 
detachment  should  be  effected  by  working  from  below  upwards,  and 
should  be  continued  until  all  adhesions  have  been  separated  and  the  ovary 
and  tube  remain  attached  to  the  uterus  and  broad  ligament  by  their 
anatomical  connections  only.  The  pedicle  is  tied  and  divided  as  in  the 
operation  of  removal  of  the  normal  uterine  appendages  for  uterine 
myoma.  The  appendages  of  the  other  side  are  now  to  be  examined  : 
if  they  are  found  diseased  they  should  be  removed ;  if  merely  adherent 
the  operator  may  content  himself  with  separating  adhesions. 

It  often  happens  that  during  the  manipulations  just  described  there 
is  an  escape  of  pus.  This  is  not  necessarily  due  to  any  fault  of  the 
operator;  it  is  usually  the  inevitable  result  of  separating  adhesions 
around  the  mouth  of  a  suppurating  and  adherent  tube,  or  of  enucleat- 
ing a  suppurating  and  adherent  ovary  whose  wall  is  ulcerated  and  on 
the  point  of  bursting.  Fortunately,  it  is  only  when  the  pus  is  unusu- 
ally virulent  that  serious  harm  results  from  its  escape. 

Sometimes  it  becomes  obvious  during  the  operation  that  persistence 
in  the  separation  of  adhesions  would  expose  the  patient  to  unjustifiable 
risk,  either  from  unduly  prolonging  the  operation,  or  from  the  danger  of 
injuring  the  surrounding  viscera.  This  is  specially  apt  to  occur  in  the 
case  of  suppurating  ovarian  cysts.  The  operator  will  find,  however,  that 
the  cases  in  which  it  becomes  necessary  for  him  to  desist  from  attempts 
at  entire  removal,  and  to  content  himself  with  emptying  and  draining  the 
suppurating  cavity,  will  diminish  as  his  experience  increases.  The  separa- 
tion of  adhesions  to  parts  of  the  intestine  other  than  the  rectum  should 
be  undertaken,  whenever  practicable,  with  the  parts  well  in  view;  and 
any  injury  sustained  by  the  bowel  during  the  process  should  be  repaired 
at  once.  One  of  the  chief  risks  of  the  operation  is  the  liability  of  mis- 
taking thickened  and  adherent  intestine  for  an  inflamed  Fallo})ian  tube. 
The  risk  is  best  obviated  by  rigidly  following  the  rule  of  identifying  the 
tube  V)y  tracing  it  from  its  uterine  end  outwards,  before  commencing  to 
separate  adhesions. 

Whenever  it  is  obvious  that  the  ovary,  notwithstanding  the  adhesions 
with  which  it  is  surrounded,  is  itself  free  from  disease,  it  is  good  ])ractice 
not  to  remove  it.  If  even  one  ovary  can  be  preserved  it  will  jirevent  the 
arrest  of  the  menstrual  function,  and  so  will  save  the  pati(;nt  from  the 
discomforts  that  attend  the  premature  induction  of  the  menopause. 

The  rule  to  remove  only  such  parts  as  are  diseased  is  a  sound  one : 
but  in  the  case  of  tubal  disease,  where  the  gross  lesion  is  limited  to  one 


PELVIC  INFLAMMATION  517 

side,  the  apparently  healthy  tube  of  the  opposite  side  should  always  be 
carefully  examined.  If  pus  exude  from  it  on  pressure  the  proper  course 
is  to  remove  the  tube,  notwithstanding  the  absence  of  thickening  of  its 
Avails  or  other  obvious  sign  of  disease.  It  not  unfrequently  happens 
that  the  tube  opposite  to  that  which  is  chiefly  affected,  though  not 
actually  diseased,  has  become  transformed  into  a  retention  cyst  (hydro- 
salpinx) by  occlusion  of  its  abdominal  ostium  by  peritonitis.  In  such  a 
case  either  the  tube  should  be  removed,  or  its  contents  should  be  evacuated 
and  a  portion  of  its  wall  excised. 

Every  care  should  be  taken  during  this  operation  to  avoid  opening 
the  general  peritoneal  cavity,  if  it  be  possible.  The  toilet  of  the  peri- 
toneum, after  the  operation  has  been  completed,  should  be  effected,  if 
necessary,  by  plentiful  douching  with  hot  water  (temp.  105°  F.)  rather 
than  by  the  vigorous  use  of  the  sponge  or  any  of  its  substitutes.  The 
insertion  of  a  drainage  tube  is  a  point  that  must  be  left  to  the  judgment 
of  the  operator  in  each  individual  case.  The  use  of  the  drainage  tube 
(or  strip  of  gauze  which  is  its  equivalent)  tends  to  diminish  in  frequency 
as  experience  increases. 

With  regard  to  other  matters  that  concern  the  technique  of  this 
operation,  in  common  with  that  of  abdominal  operations  in  general,  the 
reader  is  referred  to  the  articles  on  pelvic  surgery.  One  point,  how- 
ever, in  connection  with  the  closing  of  the  abdominal  incision  may  be  here 
mentioned.  It  has  been  found  greatly  to  lessen  the  risk  of  hernia  if, 
before  tying  the  silk-worm  gut  sutures  that  pass  through  the  entire 
thickness  of  the  abdominal  wall,  the  edges  of  the  sheath  of  the  rectus 
muscle  are  brought  carefully  into  apposition  by  means  of  a  continuous 
catgut  suture.  This  is  preferable  to  suturing  the  abdominal  wall  in 
layers,  which  method  is  apt  to  leave,  between  the  various  layers,  interspaces 
that  facilitate  the  lodgment  of  serous  and  other  inflammatory  effusions. 

The  after-treatment  differs  in  no  respect  from  that  of  other  abdominal 
operations. 

Within  the  last  few  years  another  method  of  operating  in  these  cases 
has  come  into  rivalry  with  that  by  abdominal  section.  This  newer 
operation — first  proposed  and  carried  out  by  Pean  in  1886,  and  since 
popularised,  though  in  the  face  of  much  opposition,  by  the  earnest 
advocacy  of  Segond  and  others  —  consists  in  the  removal  of  the  uterus 
through  the  vagina,  supplemented  or  not,  according  to  circumstances,  by 
the  removal  of  the  diseased  uterine  appendages.  It  is  argued  by  the 
supporters  of  this  method  that  the  return  of  pelvic  pain  and  tenderness, 
met  with  in  certain  cases  after  the  removal  of  diseased  uterine  appendages 
by  abdominal  section,  is  due  to  the  fact  that  the  uterus,  the  original 
source  of  all  the  trouble,  is  left  behind.  By  the  removal  of  the  uterus 
through  the  vagina  in  the  first  instance,  it  is  maintained  that  not  only 
is  the  attack  made  upon  the  original  seat  of  the  inflammation,  but  that 
so  excellent  a  channel  is  established  for  drainage  that  abscess  cavities, 
whether  in  the  tubes  or  ovaries,  or  amongst  the  peritoneal  adliesions, 
can  be  readily  evacuated.     Thus,  in  many  cases,  it  is  said  to  be  un- 


5i8  SYSTEM   OF  GYNECOLOGY 

necessary  to  proceed  to  the  removal  of  the  diseased  appendages  them- 
selves-. The  operation,  though  its  precise  position  and  value  have  not 
yet  been  settled,  has  now  been  adopted  by  a  sufficiently  large  number 
of  influential  operators  to  have  established  for  itself  a  claim  to  the 
serious  consideration  of  all  who  are  interested  in  the  advance  of  gynae- 
cological surgery. 

The  first  steps  of  the  operation  are  much  the  same  as  in  the  ordinary 
operation  of  vaginal  hysterectomy.  The  patient  is  prepared  by  the 
administration,  for  several  days  before  the  operation,  of  vaginal  douches 
of  solution  of  corrosive  sublimate  guViy?  ^^^  ^1  ^^  usual  purge  and 
enema  a  few  hours  before  the  operation  is  to  take  place. 

At  the  time  of  operation  the  patient  is  placed  in  the  lithotomy 
position,  and  four  large  vaginal  retractors  (preferably  those  of  Pean)  are 
introduced  —  one  anteriorly,  one  posteriorly,  and  one  on  each  side.  An 
assistant  on  the  left  side  takes  charge  of  tAvo  of  these,  and  one  on  the 
right  of  the  other  two.  The  cervix  is  drawn  down  by  means  of  a 
volsella  and  a  circular  incision  made,  the  incision  being  nearer  the 
OS  externum  anteriorly  than  posteriorly,  where  it  may  be  half  an  inch 
above  it.  In  order  to  give  additional  room  two  lateral  incisions  are  now 
made  in  the  vaginal  wall,  each  about  two-thirds  of  an  inch  long,  running 
outwards  from  the  circular  incision  and  parallel  with  the  lower  border 
of  the  broad  ligament.  The  tip  of  the  anterior  retractor  being  now 
placed  in  the  wound,  the  bladder  and  cervix  are  separated,  as  far  as  is 
practicable,  by  means  of  successive  snips  with  the  blunt-pointed  curved 
scissors.  The  scissors  are  held  with  the  concavity  of  the  curve  towards 
the  uterus,  so  as  to  avoid  the  bladder  and  keep  as  near  to  the  uterus 
as  possible.  The  attachments  of  the  cervix  posteriorly  are  now  divided, 
partly  by  the  scissors  and  partly  by  the  finger,  a  retractor  again  being 
used  to  pull  back  the  liberated  tissue.  The  next  step  is  to  secure  by 
ligature  or  forceps  the  lowermost  inch  of  the  broad  ligament  including 
the  uterine  artery.  This  is  done  by  gliding  the  forefinger  of  the  left 
hand  outward  over  the  anterior  surface  of  the  cervix  towards  the  base 
of  the  broad  ligament,  pushing  aside  the  ureter  and  penetrating  between 
the  anterior  peritoneal  fold  and  the  ligament  proper.  The  same  having 
been  done  l)ehind,  the  lowermost  inch  of  the  broad  ligament  is  grasped 
between  the  fingers  and  secured  by  ligature  or  clamp-forceps.  The 
attachments  of  the  ligament  to  the  uterus  are  now  divided,  close  to  the 
uterine  tissue,  to  a  height  corresponding  with  tliat  of  the  section  secured. 
The  opposite  side  is  dealt  with  in  the  same  way.  The  cervix  is  then  slit 
up  on  each  side  so  as  to  divide  it  into  two  flaps,  anterior  and  posterior. 
The  posterior  flap  is  cut  off,  the  anterior  is  seized  with  strong  forceps 
and  drawn  well  down,  and  a  further  separation  of  the  bladder  is  effected. 
The  stumj)  having  been  secured  against  retraction  by  seizing  it  with  a 
'•  bullet-ti-action  "  forceps  above  the  line  of  amputation,  the  anterior 
cervical  flap  is  now  cut  off.  The  next  stage  of  tlic;  ojjeriition  consists  'w\ 
the  removal  piecemeal — by  morccllation  as  it  is  technically  termed — of 
the  anterior  wall  of  the  uterus.     The  stump  Ijeing  pulled  down  ])y  means 


PELPVC  INFLAMMATION 


519 


of  a  traction  forceps  inserted  into  each  side,  the  uterus  is  still  further 
separated  from  the  bladder,  and  small  pieces,  extending  through  the 
entire  thickness  of  the  anterior  uterine  wall,  are  removed  with  scissors 
or  knife  by  a  succession  of  vertical  or  oblique  sections  in  the  middle  line. 
The  forceps  are  successively  re-inserted  higher  up,  the  uterus  is  further 
drawn  down  and  set  free,  and  the  morcellation  is  repeated,  until  the 
peritoneal  cavity  is  reached.  The  fundus  uteri  now  descends  sufficiently 
to  allow  of  its  being  hooked  down  by  the  operator's  finger  and  everted. 
Such  adhesions  as  exist  posteriorly  can  be  seen  and  separated,  and  the 
upper  portion  of  each  broad  ligament  is  then  secured  by  one  or  more 
ligatures  or  by  forceps,  and  the  separation  of  the  uterus  completed.  To 
facilitate  this  part  of  the  o^Deration  some  surgeons  divide  the  uterine 
stump  longitudinally  and  deal  with  each  half  separately. 

The  advantage  of  morcellation  is  "that  the  operator  sees  exactly- 
what  is  being  done,  step  by  step."  If,  during  the  separation  of  adhesions, 
pus  is  seen  to  escape,  the  opening  into  the  pus  cavity  is  enlarged  by  the 
operator's  finger,  the  cavity  is  washed  out,  and  the  operation  resumed. 
When  it  is  possible  to  separate  the  adhesions,  the  inflamed  uterine 
appendages  should  be  gently  pulled  down  into  the  vagina,  ligatured  or 
clamped,  and  removed.  If  the  tubes  present  themselves  as  large  coils 
distended  with  pus,  the  surroimding  parts  are  protected  by  means  of 
small  mounted  sponges,  and  the  tubes  are  opened  with  the  knife  in 
such  a  Avay  that  the  contents  escape  into  the  vagina  without  soiling  the 
peritoneum.  The  edges  of  the  opening  are  seized  with  forceps  to  guard 
against  retraction,  and  the  cavity  is  irrigated  Avith  solution  of  corrosive 
sublimate.  The  tubes  should  then,  if  possible,  be  removed  by  enuclea- 
tion with  the  fingers.  If  this  be  found  impracticable,  they  may  be  left 
to  drain  and  undergo  atrophy.  Search  should  be  made  with  the  fingers 
for  any  out-lying  abscesses,  in  order  that  they  may  be  opened  and 
drained.  Where  the  inflamed  appendages  are  situated  high  up,  and  are 
so  densely  adherent  that  they  cannot  be  drawn  down  into  view,  their 
separation  has  to  be  effected,  if  effected  at  all,  by  the  aid  of  the  sense 
of  touch  as  in  the  older  operation. 

Many  modifications  of  the  operation  have  been  introduced,  but  the 
above  account  embraces  the  leading  features  of  the  method  practised  by 
the  most  successful  operators. 

The  dressings  of  the  Avouud  are  the  same  as  in  ordinar}^  vaginal 
hysterectomy.  Iodoform  gauze  should  be  packed  lightly  into  any  pus 
cavities  that  have  been  left,  and  removed  with  the  tampons  in  six  days. 
If  clamps  have  been  used,  they  must  be  removed  in  forty-eight  hours. 
An  enema  is  administered  on  the  third  day,  and  from  that  time  nour- 
ishing food  is  given.^ 

It  is  claimed  for  this  operation  that,  whilst  its  mortality  is  no  higher, 

1  The  above  account  is  for  the  most  part  abridged  from  tlie  admirable  dcscrijition  of 
the  operation  contained  in  a  paper  by  Dr.  Edj^jar  Garceau,  entitled  "  Vajiinal  Hyster- 
ectomy as  done  in  France,"  in  tlie  American  Journal  of  Obstetric.i,  March  ISVo,  to  which 
and  to  the  writings  of  Segond,  Richelot,  Jacobs,  Leopold,  A.  Martin,  and  Landau,  the 
reader  is  referred  for  fuller  details. 


520  SYSTEM  OF  GYNAECOLOGY 

and  perhaps  even  less  high  than  that  of  abdominal  section  (undertaken 
for  the  same  object)  it  enables  the  operator  to  see  better  what  he  is 
doing;  it  is -attended -with  less  shock;  it  ensures  far  better  drainage; 
and  it  does  away  with  the  liability  to  ventral  hernia  and  to  troublesome 
sinuses  in  the  line  of  incision.  It  is  also  urged  that  inasmuch  as  the 
uterus  was  the  seat  of  the  original  lesion,  and  may  become  the  source 
of  re-infection,  its  removal  must  be  a  distinct  gain. 

The  validity  of  most  of  these  claims  need  not  be  questioned ;  but 
there  are  some  points  in  the  essential  feature  of  the  operation  —  namely, 
the  removal  of  the  uterus  —  that  do  not  appear  to  have  received  ade- 
quate consideration.  To  remove  an  organ  because  its  lining  membrane 
is  inflamed  can  scarcely  be  accepted  as  coming  within  the  domain  of 
legitimate  surgery,  unless  it  can  be  shown  (1)  that  the  inflammation  does 
not  tend  to  subside  spontaneously  ;  (2)  that  there  is  no  other  efficient 
means  of  treatment,  and  (3)  that  the  retention  of  the  organ  is  likely  to 
be  a  source  of  greater  danger  than  the  operation  undertaken  for  its 
removal.  In  all  these  respects  the  uterus  is  in  a  different  position  from 
the  Fallopian  tube,  and  an  operation  that  would  be  perfectly  justifiable 
in  the  case  of  an  inflamed  tube  would  not  necessarily  be  justifiable  in  the 
case  of  an  inflamed  uterus.  The  uterus  has,  in  its  cervical  canal,  a 
natural  outlet  for  its  morbid  secretions.  The  tube  has  no  such  natural 
outlet ;  its  morbid  secretions  either  become  pent  up  in  the  closed  tube, 
or  escape  through  the  abdominal  ostium  into  the  peritoneum.  In  either 
case  they  are  retained  within  the  body,  and  hinder  the  natural  process  of 
recovery,  which,  in  the  case  of  the  uterus,  is  carried  on  without  any  such 
impediment.  Again,  in  regard  to  accessibility  for  local  treatment,  the 
uterus  and  the  Fallopian  tube  are  on  a  totally  different  footing ;  the 
interior  of  the  uterus  is  easily  within  reach,  its  lining  membrane  can  be 
swabbed,  douched,  and  curetted  at  will.  The  Fallopian  tube,  on  the 
contrary,  is  beyond  the  reach  of  all  these  therapeutic  measures.  We 
have  no  means,  such  as  we  have  in  the  case  of  the  uterus,  of  facilitating 
the  natural  process  of  cure  by  local  treatment. 

As  to  the  possibility  of  the  uterus  becoming  a  source  of  re-infection, 
it  must  be  remembered  that  although  it  is  of  course  possible,  after  the 
removal  of  the  appendages,  for  the  uterus  to  re-infect  the  peritoneum  and 
become  a  source  of  fresh  mischief,  there  is  no  actual  evidence  that  this 
has  happened.  The  danger  is  purely  hypothetical.  On  the  other  hand, 
there  is  abundant  evidence  to  show  that  the  uterus  may  become  per- 
fectly sound.  Thus,  instances  are  by  no  means  infrequent  in  which 
removal  of  the  inflamed  appendages  for  disease  limited  to  one  side  has 
been  followed  by  pregnancy,  the  best  proof  the  uterus  could  give  of  the 
soundness  of  its  condition  and  the  completeness  of  its  cure. 

The  conclusion  to  be  drawn  from  these  considerations  is  that  the 
indisci-iniinate  removal  of  the  uterus  in  all  cases  of  operation  for 
inflammatory  disease  of  the  appendages  is  unjustifiable,  and  that  the 
vaginal  operation  ought,  at  any  rate,  never  to  be  undertaken  unless  it 
be  certain  that  tlie  appendages  of  both  sides  are  seriously  involved  in 


PELVIC  INFLAMMATION  521 

the  disease,  and  that  conception  and  pregnancy  would  be  practically 
impossible. 

Even  apart,  however,  from  this  fundamental  question  of  the  propriety 
of  removing  the  uterus,  the  admitted  advantages  of  the  newer  operation  are 
not  without  counterbalancing  disadvantages.  The  operation  is  one  of 
great  difficulty  and  cannot  always  be  completed.  It  sometimes  happens, 
indeed,  that,  after  the  uterus  has  been  extirjmted,  it  is  necessary  to 
perform  abdominal  section  in  order  to  remove  the  adnexa.  Again,  there 
is  greater  danger  than  in  the  abdominal  operation  of  injuring  the  bladder 
and  the  ureter,  and  probably  also  the  rectum.  It  has  been  said  that 
another  of  the  special  risks  of  the  vaginal  operation  is  haemorrhage  ;  but 
this  is  a  danger  to  be  eliminated  by  an  improved  technique. 

If,  however,  the  vaginal  operation  proves  in  its  results  to  be  superior 
to  the  abdominal  operation,  no  merely  theoretical  considerations  ought 
to  prevent  or  will  prevent  its  gradual  adoption.  The  time  has  not  yet 
arrived  for  pronouncing  a  final  judgment  on  the  merits  of  the  two 
operations,  or  (if,  as  seems  likely,  both  of  them  eventually  find  a 
legitimate  and  permanent  place  in  operative  gyneecology)  for  drawing 
up  a  formal  and  authoritative  statement  of  the  respective  indications 
for  the  one  operation  or  the  other.  In  the  meantime  there  can  be  no 
doubt  that  the  vaginal  operation  is  at  present  growing  in  favour,  and  that 
amongst  recent  converts  are  to  be  found  men  whose  recognised  sobriety 
of  judgment  compels  attention  to  their  views. 

There  still  remains  another  class  of  cases  in  which  operative 
interference  is  occasionally  attended  with  signal  benefit,  that,  namely, 
in  which  much  suffering  and  more  or  less  disablement  are  caused  not  by 
definite  inflammatory  changes  in  the  tube  or  ovary,  but  by  peritonitie 
adhesions.  The  salpingitis  that  originallj^  started  the  pelvic  peritonitis 
may  have  subsided  so  that  there  may  no  longer  be  any  definite  swelling 
in  the  sides  of  the  pelvis,  and  yet  the  peritonitis  may  have  left  the  pelvic 
viscera  matted  together  by  adhesions  of  such  a  kind  as  to  condemn  the 
patient  to  a  life  of  invalidism.  In  a  large  number  of  these  eases  the 
uterus  is  fixed  in  a  position  of  retro-displacement.  Under  these  circum- 
stances separation  of  the  adhesions  and  permanent  restoration  of  the 
uterus  to  its  normal  position  often  succeed  in  removing  the  symptoms 
and  restoring  the  patient  to  health. 

As  in  the  operation  for  the  removal  of  the  diseased  appendages,  there 
are  two  principal  methods  of  operating  from  which  to  choose ;  namely, 
abdominal  section  and  operation  per  vaginam.  In  the  former,  an  incision 
of  sufficient  length  to  admit  of  two  fingers  is  made  in  the  middle  line, 
terminating  an  inch  above  the  pubes.  The  uterus  and  its  appendages 
are  carefully  liberated  from  their  adhesions,  and  the  uterus,  having  been 
lifted  up  into  its  normal  position,  is  secured  in  that  position  either  by 
suturing  the  anterior  surface  of  the  uterus  to  the  abdominal  wall  (ventro- 
fixation) or  by  inserting  a  Hodge's  pessary  into  the  vagina. 

In  a  certain  small  number  of  cases  in  which  there  are  no  formidable 
adhesions  between  the  body  of  the  uterus  and  the  bladder,  and  in  which 


522  SYSTEM  OF  GYNAECOLOGY 

the  posterior  adhesions  are  not  very  firm  or  very  extensive,  the  separation 
of  the  adhesions  and  the  fixation  of  the  uterus  in  its  normal  position 
can  be  accomplished  per  vaginam  by  Dllhrssen's  operation  of  anterior 
colpotomy.  This  operation  consists  in  drawing  down  the  cervix, 
separating  the  bladder,  and  dividing  the  utero-vesical  fold  of  the 
peritoneum.  Access  to  the  peritoneal  cavity  is  thus  obtained  through 
the  anterior  vaginal  fornix.^  Two  or  three  fingers  are  then  passed  up, 
the  fundus  is  seized  and  drawn  forwards,  adhesions  are  carefully  broken 
down,  the  pelvic  viscera  are  liberated,  and,  finally,  the  uterus  is  secured 
in  its  normal  position  of  anteversion  by  the  procedure  known  as  vaginal 
fixation.  At  the  close  of  the  operation  the  peritoneal  and  vaginal  wounds 
are  closed  by  means  of  continuous  catgut  sutures. 

The  separation  of  peritonitic  adhesions  in  the  pelvis  can  occasionally 
be  effected,  without  operation,  by  the  manipulative  methods  associated 
respectively  with  the  names  of  B.  S.  Schultze  and  Thure  Brandt.  But 
these  methods  have  not  found  favour  in  this  country,  nor  are  they  likely 
to  do  so.     The  objections  to  them  are  too  obvious  to  need  discussion. 

Charles  J.  Cullingworth. 


REFERENCES 

1.  Anderson,  W.,  and  Makins,  G.  H.  "  The  Planes  of  Subperitoneal  and  Subpleural 
Connective  Tissue,  with  their  Extensions,"  Journal  of  Anatomy  and  Physiology, 
vol.  XXV.  part  1,  Oct.  18;)0,  p.  78. — 2.  Aran,  F.  A.  Lzi;ons  cUniques  snr  les  maladies 
de  V uterus  et  se.i  annexes,  pp.  569-750.  Paris,  1858. — 3.  Bandl,  L.  "  Krankheiten 
der  Tuben,  der  Lisii-mente,  des  Beckenperitoneum  und  des  Beckenbindegewebes," 
Deutsche  C'hirtirf/ie  ;  herausg.  von  Billroth  und  Luecke,  Lieferung  5i).  Stuttgart, 
1886. — 4.  Bernutz,  G.,  and  Goupil,  E.  Clinical  Memoirs  on  the  Diseases  of  Women. 
Transl.  and  edit,  by  A.  Meadows,  2  vols.  New  Syd.  See.  Lond.,  1866-67. — 5.  Byford, 
H.  T.  "  Iiiriauunatory  Lesions  of  the  Pelvic  Peritoneum  and  Connective  Tissue," 
Clinical  Gyxsecoloriy  by  American  authors.  Edit,  by  Keating  &  Coe,  vol.  i.  Edin.  1895, 
pp.  400-460. — 6.  Champneys,  F.  H.  "On  the  Removal  of  the  Uterine  Appendages," 
St.  Burlh'jlomeio's  Hosp.  R-iports,  vol.  xxix.  for  ISiK?,  pp.  45-G2.  — 7.  Cullingworth,  C. 
J.  "  The  Etiological  Importance  of  Gonorrhoea  in  Relation  to  some  of  the  more  common 
Diseases  of  Women,"  Jirit.  Med.  Journ.  July  20,  1889.  — 8.  Ibid.  "On  the  Differential 
Diagnosis  of  Pelvic  Inflammations  in  the  Female,"  Brit.  Med.  Journ.  Dec.  27,  1890. — 
9.  Ibid.  "The  Value  of  Abdominal  Section  in  certain  Cases  of  Pelvic  Peritonitis," 
Trans.  Obst.  S>c.  Lond.  vol.  xxxiv.  for  1892,  pp.  254-429.  — 10.  Ibid.  "On  Pelvic 
Peritonitis  in  the  Female,  and  the  Pathological  Importance  of  the  Fallopian  Tubes  in 
Connection  tlierevvitJi,"  lirit.  Med.  Journ.  Aug.  12,  189.3.  — 11.  Ibid.  "On  Pelvic 
Abscess,"  Birminf/ham  Med.  Review,  Nov.  1893.  — 12.   Ibid.     "Three  Cases  of  Pelvic 

1  The  operation  will  be  found  described  in  detail  in  Duhrssen's  Manual  of  Gynseco- 
lof/ical  Practire,  translated  by  Taylor  and  Edge.  London,  Lewis,  1895,  pp.  54  et  seq. 
TJiough  it  finds  its  most  frequent  and  useful  application  in  the  cases  above  referred  to, 
the  operation  can  lu;  utilised  for  many  other  purpos(!S,  sncli,  for  example,  as  the  removal 
of  small  pedunculated  subpei-itoneal  inyomata,  of  small  and  not  too  adiierent  tumours  of 
the  ovary,  of  tiil)al  gestation-sacs,  and  of  diseased  utcu-ine  ai)pendages  when  these  can  be 
flrawn  into  tins  vagina.  The;  advantages  of  this  over  the  abdominal  operation  are  tliat  it 
is  less  dangr;rons,  and  that,  fjwing  to  tiie  position  of  the  scar,  adhesions  and  hernia  of  the 
intestine  and  omentum  are  avoified.  Its  scojje,  however,  is  limited,  inasmucili  as  it  is 
only  ap|)licable  to  cases  wh(!re  t)ie  cervix  can  be  drawn  down  to  the  vaginal  (entrance, 
arid  where,  if  tlierf;  is  any  mass  to  be  removed,  the  size  of  the  mass  does  not  much,  if  at 
all,  exceed  llial,  <if  tlie  fist. 


PELVIC  INFLAMMATION  523 

Inflammation  attended  with  Abscess  of  the  Ovary,"  Trans.  Obst.  Soc.  Land.  vol.  xxxvi. 
for  IS'.ll,  pp.  277-.:%.  — 13.  Gushing,  E.  \V.  "The  Pathology  and  Diagnosis  of  so- 
called  Pelvic  Cellulitis,"  Annals  of  GynsBcohgy,  Boston,  U.  S.  A.  March  1889.  — 14. 
Delbet,  p.  Des  suppurations  pelviennes  chez  la  feinnie.  Paris,  18!)1.  — 15.  Doran, 
A.  "The  Treatment  of  Chronic  Disease  of  the  Uterine  Appendages,"  Trans.  Med.  Soc. 
Load.  vol.  x\v.  London,  18'.)1,  pp.  2oI)-251.  —  Ki.  Ibid.  "The  Relations  to  each  other 
of  Inflammation  of  the  Endometrium,  Fallopian  Tube,  Ovary,  and  Pelvic  Peritoneum," 
Trans.  Obst.  Sue.  Land.  vol.  xxxii.  for  1885,  p.  K'A. — 17.  Duncan,  J.  IMatthews. 
A  Practical  Treatise  on  Perimetritis  and  Parametritis.  Edin.  1869.  — 18.  Ibid. 
'■  On  Hffimorrhagic  Parametritis,"  Trans.  Obst.  Soc.  Lond.  vol.  xxix.  for  1887,  pp. 
191-197.  — 19.  Duncan,  W.  "On  Chronic  Diseases  of  the  Uterine  Appendages," 
Trans.  Med.  Soc.  Lond.  vol.  xiv.  London,  1891,  pp.  214-239. —20.  Griffith,  W.  S. 
A.  "Perimetric  Abscess,"  Trans.  Obst.  Soc.  Lond.  vol.  xxiv.  for  1882,  p.  299;  "Retro- 
Uterine  Perimetric  Abscess,"  Ibid.  vol.  xxv.  for  1883,  p.  18  ;  "  Serous  Perimetritis,"  Ibid. 
vol.  xxvii.  for  18S5,  p.  I(j8 ;  "Anterior  Perimetritis  and  Anterior  Parametritis,"  Ibid. 
vol.  xxix.  for  1887,  p.  147;  "Parametritis  dextra,"  Ibid.  vol.  xxx.  for  1889,  p.  5.  —  21. 
Ibid.  "Perimetritis  and  Parametritis,"  St.  Barthol.  Hosp.  Reports,  vol.  xvi.  for  1880, 
pp.  285-305.  — 22.  Ibid.  "A  Fatal  Case  of  Perimetritis,"  Ibid.  vol.  xviii.  for  1882, 
pp.  291-29().  —  23.  Herman,  G.  E.  "Lectures  on  Parametritis,"  Clinical  Journal, 
vol.  vi.  Nos.  9,  10,  11,  12.  London,  1895.-24.  Jones,  Mary  A.  Dixon.  "Removal 
of  the  Uterine  Appendages,"  3/e(L  Record.  New  York,  Aug.  21,  188(). — 25.  Keiller, 
W.  "Pelvic  Peritonitis  and  Cellulitis."  Amer.  Journ.  of  Obst.  vol.  xxviii.  No.  3. 
New  York,  1893.  —  20.  Levvers,  A.  H.  N.  "Double  Pyosalplnx  with  Rupture  of  the 
Tubes,"  Trans.  Obst.  Soc.  Lond.  vol.  xxvii.  for  1885,  p.  298. — 27.  Ibid.  "Note  on 
the  Post-mortem  Appearances  of  a  Phlegmon  of  the  Broad  Ligament,"  Ibid.  vol.  xxx. 
p.  7.  —  28.  M'Clintock,  A.  H.  Clinical  Memoirs  on  Diseases  of  Women.  Dublin, 
1863.  —  29.  Macdonald,  A.  "Latent  Gonorrhcsa  in  the  Female  Sex,  with  special 
Relation  to  the  Puerperal  State,"  Obst.  Journ.  Gt.  Brit.  vol.  i.  1873,  p.  254  (Abstract). 
—  30.  Martin,  A.  "  Ueber  Tubenerkrankung,"  Zeitschr.  fiir  Geburtshlilfe  uml 
Gynukoloiiie,  Bd.  xiii.  Stuttg.  1886,  pp.  298-311. —  31.  Ibid.  "  Colpotomia  anterior," 
Monatsschrift  fiir  Geburtskiilfe  iind  Gijniikologie.  Berl.  Aug.  1895. — 32.  Ibid.  Die 
Krankheiten  der  Eileiter,L,eipz.  18Q'>.  —  33.  Maury,  R.  B.  "How  shall  we  treat  our 
Cases  of  Pelvic  Inflammation?"  Amer.  Journ.  of  Obst.  vol.  xxiv.  No.  1.  New  York, 
1891. — 34.  Ibid.  "The  Present  State  of  our  Knowledge  of  Pelvic  Inflammation,  with 
Special  Reference  to  the  Treatment  of  Pelvic  Abscess,"  Amer.  Journ.  of  Obst.  \o\.  xxviii. 
No.  6.  New  York,  1893. — 35.  Menge,  K.  "Ueber  die  gonorrhoische  Erkrankung  der 
Tuben  und  des  Bauchfells,"  Zeitschr.  fiir  Geburtshiilfe  und  Gijncikologie.  Band  xxi. 
Stuttg.  1891,  pp.  119-159. — 36.  Monprofit.  Elude  chir-urgicale  sur  les  inttatnmations 
des  organes  genitaux  internes  de  la  femme  :  salpingites  et  ovarites.  Paris,  1888. — .37. 
Noeggerath,  E.  Die  latente  Gonorrhoe  ini  weiblichen  Geschlecht.  Bonn.  1872.  —  38. 
Ibid.  "  Ueber  latente  und  chrouische  Gonorrhoe  beini  weiblichen  Geschlecht," 
Deutsche  medicin.  Wochenschrift ,  1877,  No.  49.  Berlin.  —  39.  Polk,  W.  M.  "A 
Study  of  Peri-uterine  Inflammation  in  its  Relation  to  Salpingitis,"  Trans.  Assoc.  Amer. 
Physicians,  vol.  i.  Philad.  1886,  pp.  145-169. — 40.  Ibid.  "Inflammations  of  the 
Uterine  Appendages  and  Peritoneum,"  Clinical  Gi/nxcology  by  American  Authors. 
Edit,  by  Keating  and  Coe,  vol.  i.  Edin.  1895,  pp.  3.3.5-382.-41.  Pozzi,  S.  T?riitc 
de  gynecologic,  2me  c'dit. — 42.  Rosthorn,  A.  V.  "  Vierzig  Falle  von  Abtragung  und 
Entfernung  der  Anhiinge  der  Gebiirmutter,"  Archiv  fiir  Gyndkologie,  Bd.  xxxvii.  Berl. 
ISDO,  pp.  337^19. — 43.  Sanger,  Max.  "Ueber  die  Beziehungen  der  gonorrhoischen 
Infektion  zu  puerpcral-Erkrankungen,"  Verh.  derdeutsch.  Gesellschaftfiir  Gyniikologie. 
Leipz.  1886. — 44.  Ibid.  Die  Tripperansteckung  beim  tceiblichen  Ge-tchlechte.  Leipz. 
1889.  —  45.  Second,  P.  De  rhysterectomie  vaginal  dans  le  traitement  des  suppurations, 
pelviennes.  Paris,  1891. — 46.  Sinclair,  W.  Japp.  On  Gonorrhwal  Infection  in 
Women.  London,  1888.  —  47.  Schmitt,  A.  "  Zur  Kenntniss  der  Tubengonorrhiie," 
Archiv  fiir  Gyniik.  Band  xxxv.  Berlin,  1889,  pp.  162-186. — 48.  Tait,  Lawson. 
"  On  the  Treatment  of  Pelvic  Suppuration  by  Abdominal  Section  and  Drainage,"  Med. 
Chir.  Trans,  vol.  Ixiii.  for  1880,  pp.  307-316.-49.  Ibid.  "Recent  Advances  in 
Abdominal  Surgery,"  Trans.  Int.  Med.  Cong.  1881,  vol.  ii.  p.  228.  London. — .50. 
Ibid.  Di.':eases  of  Wonvn  and  Abdoinuial  Surgery,  vol.  i.  Leicester.  ISsi).  pp  iv.V.^- 
435.  —  51.  Ibid.  "A  Discussion  of  the  General  Principles  involved  in  the  (Operation 
of  Removal  of  the  Uterine  Appendages,"  Xew  York  Med.  Journ.  Nov.  20.  1SS(\.  —  52. 
Targett,  J.  II.  "  Acute  Suppuration  and  Sloughing  of  Ovaries  after  Parturition," 
Trans.    Obst.  Soc.  Lond.  vo].  xxxvW.  for   18'.I5,  p.  21(i. — 53.    Taylor,  J.  AV.     "Clinical 


524  SYSTEM  OF  GYNECOLOGY 

Lecture  on  Pyosalpinx,  with  Remarks  on  the  old  faith  and  the  new  regarding 
Parametritis  and  Perimetritis,"  Lancet,  1889,  vol.  ii.  p.  581.  —  Si.  Terillon,  O- 
Halpiniiites  et  oi'ariles.  Paris,  1891. — 55.  Trkves,  F.  Peritonitis.  London,  18i>l. 
—  5(j.  Virch6w,  R.  "  Ueber  puerperale  diffuse  Metritis  und  Parametritis,"  Archiii 
fiir  path.  Anat.  und  Physiol,  herausg.  v.  R.  Virchow,  Bd.  xxiii.  Berl.  1862,  pp.  415- 
427.  —  57.  West,  C.  Lectures  on  Disea.^es  of  Women,  4th  edit,  by  J.  Matthews 
Duncan.  Lond.  1879,  pp.  421-452. — 58.  White,  J.  W.  "Oophorectomy  in  Gonor- 
rhoeal  Salpingitis,"  Brit.  Med.  Journ.  Feb.  19,  1889.— 59.  Williams,  Sir  J.  "On 
Serous  Perimetritis,"  Trans.  Obst.  Soc.  Lond.  vol.  xxvii.  for  1885,  pp.  169-181.  —  60. 
ZwEiFEL,  P.  "  Ueber  Salpingo-Oophorektoniie,"  Archiv  fiir  Gyndk.  Band  xxxix.  Hft. 
3,  Berl.  1891,  pp.  353-392. 

C.   J.    C. 


PELVIC   H.^MATOCELE 

Definition  and  Synonyms.  —  An  encysted  tumour  formed  by  the  ex- 
travasation of  blood  from  some  part  of  tlie  generative  organs  into  the 
pelvic  tissues  in  the  immediate  neighbourhood  of  the  uterus. 

Much  discussion  has  taken  place  concerning  the  true  definition  of 
pelvic  h^ematocele  and  the  pathology  of  it.  Thus  it  has  received  the 
various  appellations  —  ''retro-uterine  haematocele,"  "  peri-meterine  or 
peri-uterine  haematocele,"  "  hsematoma,"  "  pelvic  thrombus,"  and  the  like. 
The  term  "  pelvic  hsematocele"  is  the  most  comprehensive,  as  it  may  be 
employed  to  include  all  forms  of  tumours  in  the  true  pelvis  formed  by 
extravasated  blood,  irrespective  of  their  exact  relation  to  the  uterus,  and 
of  the  theories  of  pathologists ;  premising  always,  of  course,  that  they 
have  their  origin  in  the  reproductive  organs. 

General  Pathology.  —  Introductory.  —  It  is  comparatively  within  recent 
years  that  attention  has  been  called  to  the  subject  of  pelvic  haematocele, 
and  that  it  has  found  a  place  in  medical  nomenclature. 

Some  short  account  of  the  earlier  recorded  cases,  and  of  the  successive 
steps  tak(m  to  investigate  their  nature,  is  essential  to  the  elucidation  of 
its  pathology.  The  earliest  instances  in  which  the  recorded  facts  leave 
no  doubt  as  to  the  identity  of  the  disease  occurred  in  the  practice  of 
Rdcamier  in  the  Hotel-])ieu  in  Paris.  One  of  these  was  published  in  the 
Lancette  Fran(;aise,  July  21st,  1831,  under  the  title  "  Tumeitr  sanguine 
du  Bassin."  A  woman,  28  years  of  age,  after  a  miscarriage,  had  a  large 
tumour  in  the  true  pelvis  behind  the  uterus,  which  projected  into  the 
vagina.  K^camier,  believing  it  to  be  an  abscess,  opened  it ;  but,  instead 
of  pus,  dark,  half-coagulated  blood  escaped  from  the  aperture.  In 
1841  M.  J'.ourdon,  in  the  Rp/me  medicale,  described  the  physical  signs 
of  blood  tumours  situated  in  the  peri-uterine  cellular  tissue  of  the 
pelvis;  and  somewhat  later  Velpeau  in  his  Mhnoire  mr  les  (xivith  doses 
published  additional  cases,  and  was  evidently  acquainted  with  the  true 
character   of  these   affections.      Other   cases  were   reported  later   by 


PELVIC  HAiMATOCELE 


525 


Bernutz  and  Piogy.  Bernutz  claimed  priority  in  having  pointed  out 
in  1848  the  relation  between  pelvic  blood  tumours  and  disturbance  of 
the  menstrual  function ;  but  in  his  opinion  the  honour  of  having  first 
discovered  true  hematocele  belongs  to  Ruysch  in  1691. 

Be  this  as  it  may,  the  first  clear  and  intelligible  account  of  the 
affection  Avas  published  in  France  by  ISTelaton,  the  distinguished 
Professor  of  Clinical  Surgery  in  Paris  ;  and  to  him  belongs  the  merit  of 
bringing  the  affection  into  prominence  and  giving  it  a  jjermanent  place 
in  our  nosology.  It  was  in  1850  that  Nelaton  drew  the  attention  of 
his  class  to  the  occasional  occurrence  of  fluctuating  tumours  situated 
between  the  uterus  and  rectum,  which  on  being  laid  open  were  found  to 
contain  extra vasated  blood.  From  the  position  of  the  tumour  he  gave 
it  the  name  of  "  retro-uterine  hsematocele  "  ;  a  title  still  applied  to  it  by 
some  authors,  but  too  limited  in  its  definition :  further  investigation 
has  demonstrated  that,  besides  the  posterior  aspect  of  the  uterus, 
haematocele  is  found  in  other  localities  in  the  pelvis. 

In  1851  jM.  Xelaton  made  retro-uterine  haematocele  the  subject  of 
Clinical  Lectures,  and  these  were  subsequently  published  in  the  Gazette 
des  hdpitaux.  The  description  there  given  is  clear  and  precise ;  and 
without  detracting  from  the  merits  of  those  who  preceded  him,  it  may 
be  said  that  until  the  appearance  of  Nelaton's  Clinical  Lectures  the  sub- 
ject was  absolutely  unknown  to  the  majority  of  medical  practitioners 
in  France  and  elsewhere.  Even  in  1850  the  celebrated  surgeon 
Malgaigne  attempted  to  enucleate  a  supposed  fibroid  tumour  of  the 
uterus,  which  proved  to  be  an  encysted  collection  of  blood ;  the  opera- 
tion was  followed  by  fatal  haemorrhage. 

The  lectures  of  Nelaton  having  draAvn  attention  to  the  subject,  it  was 
soon  discovered  that  the  disease  in  question  was  by  no  means  so  rare 
as  might  be  supposed  from  the  little  which  had  been  written  upon  it. 
Many  contributions  speedily  followed.  Among  the  first  and  best  of  the 
theses  on  haematocele  was  that  of  Vigues,  a  pupil  of  Xelaton ;  and  later 
followed  those  of  Fenerly,  Voisin,  and  others.  In  1860  Voisin  pub- 
lished an  octavo  volume  on  Retro-uterine  Hcematocele  and  Non-encysted 
Extravasations  of  Blood  in  the  peritonecd  Cavity  of  the  Pelvis  ;  and  fur- 
ther contributions  were  made  in  France  by  Laugier,  Rouget,  Fenerley, 
Puech,  and  Bernutz  and  Goupil ;  in  Germany  by  Yirchow,  Scanzoni. 
Braun,  Herber,  Crede,  Breslau,  Seyfert,  and  Olshausen.  In  Great 
Britain  the  subject  received  early  notice  in  Dr.  Tilt's  Diseases  of  Women, 
and  in  lectures  published  by  Dr.  West  and  Sir  James  Simpson.  Dr. 
Barnes  especially  drew  attention  to  the  frequency  of  the  accident.  A 
numerous  array  of  instances  were  chronicled,  and  many  observers  wrote 
about  it  or  made  it  the  subject  of  discussion  in  dcl)ating  societies. 
Among  others  may  be  mentioned  Drs.  IM'Clintock,  Matthews  Duncan, 
Tuckwell,  jNfeadows,  and  I\Ladge. 

Haemorrhage  into  the  pelvic  cavity  may  take  place  in  various  posi- 
tions ;  and  it  may  issue  into  the  peritoneal  cavity,  or  outside  and  be- 
neath the  peritoneum  into  the  pelvic  cellular  tissue.      Haemorrhage, 


526  SYSTEM   OF  GYNECOLOGY 

again,  in  the  pelvis  varies  in  amount  and  in  diffusion.  It  may  be  so 
extensive  as  to  give  neitlier  tijne  nor  opportunity  for  it  to  become  en- 
cysted—  the  patient  may  die  speedily  from  shock  and  loss  of  blood  :  in 
other  cases  it  may  be  so  small  as  to  afford  very  indefinite  indications  of 
its  presence.  Further,  blood  extravasation  into  the  pelvis  may  arise 
from  a  diversity  of  causes  even  in  connection  with  the  generative  organs. 

Hence  much  controversy  has  taken  place  concerning  the  true  definition 
of  hffimatocele.  Under  the  name  "  retro-uterine  hsematocele  "  Nelaton  and 
his  followers  grouped  together  all  the  varieties  of  blood  tumour  found 
posterior  to  the  uterus  or  around  it,  irrespective  of  their  causes.  Voisin 
restricts  the  name  to  those  cases  in  which  the  blood  is  extravasated  into 
the  peritoneal  sac  between  the  uterus  and  rectum ;  and  further,  accord- 
ing to  him,  the  result  must  be  due  to  some  accident  of  menstruation. 
Bernutz,  one  of  the  earliest  and  most  authoritative  writers  on  the  sub- 
ject, insists  that  Nelaton's  grouping  is  irrational,  and  that  pelvic  haem- 
orrhage is  not  a  specific  disease  apart  from  that  which  caused  it,  but  is 
simply  a  haemorrhage  symptomatic  of  certain  morbid  conditions  which 
ought  to  be  the  main  object  of  pathological  study.  In  his  endeavour  to 
define  cases  of  true  haematocele,  Bernutz  adduces  the  analogy  between 
the  tunica  vaginalis  in  the  male  and  the  recto-uterine  cul-de-sac  in  the 
female,  —  the  only  difference  between  the  two  being  that  the  folds  of 
peritoneum  forming  the  tunica  vaginalis  are  external  to  and  shut  off  from 
the  abdominal  cavity  in  surrounding  the  testicle  ;  while  in  the  female  the 
analogous  folds  of  peritoneum,  subtending  the  two  ovaries,  together  form 
an  open  sac  communicating  with  the  general  peritoneal  cavity.  As, 
therefore,  he  would  apply  the  name  ''  haematocele  "  in  the  male  to  a  col- 
lection of  blood  in  the  tunica  vaginalis,  he  restricts  it  in  the  female  to 
collections  of  blood  in  the  retro-uterine  pouch  of  the  peritoneum ;  and, 
in  respect  of  their  causes,  to  those  blood  tumours  which  arise  from  some 
accident  of  menstruation.  It  is  obvious  that  this  definition  could  not  be 
accepted  by  many  recent  authors,  who  believe  that  ectopic  gestation  is 
the  most  frequent  cause  of  hsematocele  in  all  its  forms.  By  authors 
generally,  both  in  Great  Britain  and  elsewhere,  the  term  "  haematocele  " 
in  women  is  used  in  a  wider  and  more  comprehensive  sense ;  and  in- 
cludes tumours  formed  by  the  extravasation  of  blood  not  only  into  the 
retro-uterine  cul-de-sac  of  the  peritoneum  —  although  clinically  this  may 
be  the  most  common  — but  also  elsewhere  around  the  uterus  ;  and  more 
especially  into  the  cellular  tissue  of  the  pelvis  which  lies  outside  the 
peritoneum.  Even  in  France,  the  country  to  which  we  owe  the  largest 
amount  of  original  work  on  this  disease,  the  term  "  haematocele  "  is  now 
used  in  this  more  comprehensive  sense ;  and  Pozzi,  one  of  the  latest  and 
best  French  writers  on  Gynaecology,  adopts  this  description. 

Derangement  of  the  menstrual  fimction  is  recognised  as  a  common 
and  fertile  source  of  pelvic  luemorrhage,  Ijut  other  causes  are  not  excluded. 
The  late  J)r.  M'Clintock,  in  an  able  paper  on  this  subject,  remarks  that 
he  "cannot  agree  with  liernutz  that  to  discover  the  existence  of  pelvic 
hsematocele  constitutes  only  the  half  and  the  less  important  half  of  the 


PELVIC  HEMATOCELE  527 

diagnosis ;  on  the  contrary,  it  is,  I  should  say,  by  far  the  most  important 
half ;  for  if  we  overlooked  the  haematocele,  and  were  cognisant  only  of 
the  morbid  condition  from  which  it  had  arisen,  what  errors  of  prognosis 
and  treatment  might  we  not  commit  ?  "  As  a  practical  fact,  it  may  he 
pointed  out  that  the  treatment  of  effusions  of  blood  into  the  pelvis  must 
be  influenced  in  a  much  greater  degree  by  the  rapiditv',  extent,  and  posi- 
tion of  the  extravasation,  than  by  the  pathological  condition  which  caused 
them ;  and  although  Bernutz  is  doubtless  correct  in  his  assertion  that 
the  sanguineous  effusion  is  only  a  symptom  and  effect  of  some  pre-ex- 
isting pathological  condition —  in  the  same  sense  as  menorrhagia  may 
be  —  yet  all  Bernutz  contends  for  would  be  attained  by  bearing  in  mind 
that,  like  metrorrhagia  or  uterine  htemorrhage,  it  may  proceed  from  a 
diversity  of  pathological  causes. 

Concerning  the  anatomical  situation  of  pelvic  hsematocele,  again,  much 
controversy  has  arisen.  Voisin  and  Bernutz  only  admit  those  cases  to 
be  true  hsematocele  in  which  the  blood  is  poured  into  the  peritoneal  sac 
between  the  uterus  and  rectum.  The  instances  in  which  blood  is  extra v- 
asated  into  the  cellular  tissue,  around  the  uterus,  and  beneath  and  out- 
side the  peritoneum,  they  regard  as  cases  of  '•'  thrombus,"  akin  to  those 
blood  tumours  which  are  found  occasionally  in  the  external  genitals  in 
connection  with  the  puerperal  state,  or  produced  by  violence  and  dis- 
turbances other  than  those  associated  with  menstruation.  Accumulated 
observations  leave  no  doubt  that,  in  the  largest  number  of  cases  of 
encysted  hsematocele,  the  blood  is  situated  within  the  peritoneal  sac : 
but  there  is  abundant  evidence  to  show  that  this  is  not  invariably  so, 
and  that  the  same  influences  are  at  work  in  both  forms.  Further,  Mr. 
Lawson  Tait  and  others  have  shown  that  an  extravasation  of  blood  into 
the  pelvic  cellular  tissue  may  eventually  burst  its  restricted  boundaries 
and  be  poured  into  the  peritoneal  cavity.  It  seems,  therefore,  unwarrant- 
able to  separate  the  two  forms  of  pelvic  blood  swelling,  and  to  give 
them  separate  appellations.  Both  have  their  position  deeply  situated  in 
the  pelvis;  both  arise  from  the  rupture  of,  or  escape  of  blood  from  vessels 
supplying  the  organs  in  the  pelvis ;  and  in  both,  if  the  extravasation  be 
sufficiently  sparing  and  slow,  the  blood  becomes  encysted.  Moreover  the 
symptoms  and  physical  signs  are  often  so  much  alike  as  to  be  indistin- 
guishable. The  family  resemblance  in  the  menstrual  group  is  further 
borne  out  by  the  tendency  of  the  tumour  in  both  kinds  to  appear  about 
the  time  of  a  catamenial  period.  If  it  be  urged  that  the  ovaries, 
the  Fallopian  tubes,  and  the  uterus  are  the  organs  principally  engaged 
in  the  menstrual  act,  and  that  any  escape  of  blood  from  these  in- 
ternally is  most  likely  to  flow  into  the  ca\ity  of  the  peritoneum, 
it  may  be  pointed  out  that  during  menstruation,  and  especially  at  its 
commencement,  the  whole  generative  system  becomes  more  vascular; 
the  circulation  in  the  broad  ligaments  is  increased;  the  hannorrhoidal 
vessels  become  distended ;  all  the  pelvic  organs,  indeed,  receive  an 
increased  supply  of  blood,  and  the  abdomen  itself  becomes  fuller.  Eouget 
and  others  have  described  an  intricate  and  tortuous  plexus  of  vessels 


528  SYSTEM  OF  GYNMCOLOGY 

lying  just  beneath  the  ovary  in  the  fokis  of  the  broad  ligaments,  which 
during  menstruation  and  other  analogous  conditions  becomes  so  distended 
as  to  form  a  sort  of  erectile  organ.  This  is  termed  the  bulb  of  the  ovary. 
Anatomical  conditions  favourable  to  the  escape  of  blood  in  certain  per- 
turbed states  exist,  therefore,  in  all  the  jielvic  tissues ;  but  more  especially 
Avhen  the  catamenia  occur.  Looking  at  these  anatomical  conditions,  it 
may  be  more  obvious  how  haemorrhage  takes  place  into  the  retro-uterine 
cul-de-sac  of  peritoneum ;  yet  there  is  ample  evidence  that  blood  is 
occasionally  extravasated  into  the  cellular  tissue  in  such  quantities  as  to 
form  a  considerable  tumour.  Evidence  from  the  post-mortem  room  is 
not  sufficient  to  furnish  data  as  to  the  relative  frequency  of  the  two 
forms,  for  the  reasons  that  in  the  fatal  cases  the  extravasation  is  more 
frequently  intraperitoneal,  and  that  death  rarely  takes  place  from  the 
extraperitoneal  form.  Nevertheless  there  is  other  evidence  forthcoming 
to  prove  the  occurrence  of  the  last-named  form.  Bernutz  himself  admits 
its  existence,  but  declines  to  include  it  in  the  form  "hematocele."  The 
opinion  that  haematocele  may  be  extra-  as  well  as  intraperitoneal  was 
shared  by  MM.  Hugier,  Nonat,  Robert,  Becqueril,  Verneuil,  and  Prost. 
Xonat,  after  a  careful  study  of  this  affection  in  La  Pitie  and  elsewhere, 
states  in  his  work  on  Diseases  of  the  Uterus  that  he  believes  the  extra- 
peritoneal form  to  be  more  frequent,  though  less  grave  than  the  other ; 
and  he  believes  it  possible  to  diagnose  the  two  varieties  and  prescribe 
appropriate  treatment  for  each.  The  late  Sir  James  Simpson  published 
an  account  of  a  post-mortem  examination  where  the  blood  was  undoubtedly 
beneath  the  peritoneum  behind  the  uterus,  and  by  a  diagram  shows  the 
manner  in  which  the  serous  membrane  was  raised  up  so  as  to  form  the  roof 
of  the  cyst.  In  another  of  Sir  James  Simpson's  cases,  one  of  the  haemor- 
rhoidal  vessels  had  given  way,  and  produced  a  blood  tumour  in  the 
cellular  tissue  in  front  of  the  rectum.  Dr.  Matthews  Duncan  convinced 
himself  that  the  extraperitoneal  is  probably  a  common  form  of  the 
disease,  though  he  admits  that  the  extravasation  is  intraperitoneal  in 
many  cases.  Tuckwell  collected  forty-one  cases  where  post-mortem  ex- 
amination was  made :  of  these  the  extravasation  of  blood  was  intra- 
peritoneal in  thirty-eight;  this  only  proves  that  the  intraperitoneal 
form  is  more  fatal,  which  we  know.  Byrne  and  Beigel  believe  that  the 
extraperitoneal  variety  is  much  more  frequent  than  is  supposed,  and  the 
former  states  that  it  often  gives  rise  to  pelvic  abscess  or  cellulitis.  It 
may  be  that  some  forms  of  extraperitoneal  haematocele,  like  thrombus 
of  the  external  parts,  are  especially  associated  with  pregnancy  ;  as  the 
pelvic  vessels  are  then  much  more  distended  than  at  other  times.  If 
in  these  circumstances  rupture  of  a  vein  take  place  into  the  cellular  tissue 
of  the  l)road  ligament,  it  no  doubt  bears  an  analogy  to  thrombus  of  the 
vulva  in  the  puerperal  state;  but  it  is  deeply  situated  in  the  })elvis,  it  is 
dependent  on  the  same  causes,  attended  V>y  the  same  symj)toms,  and 
requires  much  the  same  treatment  as  the  intraperitoneal  form.  The 
existence  of  extraperitoneal  hix;matocele  is  now  definitely  admitted  by 
authors  at  home  and  abroad,  and  there  seems  no  valid  reason  why 


PELVIC  HEMATOCELE  529 

the  definition  of  haematocele  should  not  include  this  form  as  well 
as  the  other.  As  I  have  said,  the  majority  of  treatises  on  Diseases  of 
Women  adopt  this  definition,  and  it  is  convenient  as  well  as  practically 
useful. 

In  cases  of  haematocele,  therefore,  the  extravasated  blood  may  have 
two  separate  localities  :  —  I.  It  may  be  within  the  peritoneal  cavity.  II. 
It  may  be  situated  beneath  and  outside  the  cavity  of  the  peritoneum  in 
the  cellular  tissue  of  the  pelvis.  This  is  called  "  haematoma  "  by  some 
authors,  and  should  be  clearly  understood  to  be  less  grave  than  the 
former. 

I.  Concerning  the  intraperitoneal  form  of  haematocele,  it  is  necessary 
to  note  that  there  are  two  varieties  of  htemorrhage  which  differ,  not  in 
the  causes  or  sources  of  the  bleeding,  but  in  its  abundance  and  rapidity 
from  whatever  source  it  comes.  Thus,  if  haemorrhage  be  abundant  and 
rapid  no  defined  tumour  is  formed,  but  the  blood  spreads  itself  over  a 
large  surface  of  the  peritoneum,  and  the  patient  either  speedily  sinks 
from  collapse  or  dies  from  the  extensive  peritonitis.  There  is  no  time 
or  opportunity  for  the  blood  to  become  encysted,  and  hence  this  variety 
has  been  called  "  non-encysted  haematocele  or  extravasation."  If,  on  the 
other  hand,  blood  be  poured  out  in  small  quantity  and  sufficient!}'  slowly, 
it  commonly  gravitates  into  the  retro-uterine  cul-de-sac,  and  there  being 
surrounded  by  lymph  barriers  and  adhesions  which  have  been  thrown 
out  by  inflammatory  processes  of  a  protective  character,  it  becomes 
encysted.  The  way  in  Avhich  blood  becomes  encysted  to  form  haemato- 
cele in  the  retro-uterine  pouch,  as  first  described  by  Voisin,  is  as  graphic 
as  it  is  true.     He  says  — 

When  blood  escapes  from  the  ovaries,  the  tubes,  or  the  uterus,  it  falls  naturally 
behind  the  broad  ligaments  into  the  retro-uterine  peritoneal  space,  limited  before 
by  the  broad  ligaments  and  uterus,  behind  by  the  rectum  and  lateral  folds  of  the 
peritoneum,  on  all  sides  by  serous  membrane.  Above  the  cul-de-sac  is  open  and 
communicates  largely  with  the  rest  of  the  abdominal  cavity.  In  some  rare  cases 
the  blood  is  carried  in  part  into  the  vesico-uterine  space,  but  in  a  very  small  pro- 
portion compared  with  the  mass  extravasated  behind  the  uterus.  Hardly  have 
some  drops  of  blood  penetrated  into  the  serous  cavity  than  it  inflames.  This 
inflammation  results  in  speedily  establishing  adhesions  between  all  the  pelvic 
organs,  or  rather  between  their  peritoneal  coverings.  The  coils  of  intestine  are 
pushed  upwards  by  the  extravasated  fluid,  or  rise  upwards  by  their  own  lightness. 
The  collection  of  blood  encysts  rapidly,  thanks  to  the  energy  of  the  inflammation 
of  the  serous  membrane  and  the  formation  of  cellular  adhesions.  The  sides  of  the 
tumour,  then,  are  limited  —  before,  by  the  broad  ligaments  ;  behind,  by  the  rectum 
and  peritoneum;  below,  by  the  retro-uterine  cul-de-sac,'  above,  by  the  coils  of 
intestine  which,  by  their  adhesions  to  the  fundus  uteri,  the  broad  ligaments,  the 
ovaries,  the  tubes,  the  round  ligaments,  and  the  peritoneum  which  covers  the  lateral 
parts  of  the  pelvis,  form  for  the  cyst  a  sort  of  resisting  roof. 

As  will  be  seen  on  a  subsequent  page,  some  authors  hold  that  adhe- 
sions, the  result  of  pre-existing  peritonitis,  are  generally  present  before 

2  M 


530  SyST£J/  OF  GYNyECOLOGY 

blood  extravasation  takes  place,  and  tlius  help  to  form  the  cyst  wall  of 
a  retro-uterine  hfematocele. 

li.  In  the  extraperitoneal  form  the  blood  is  poured  out  into  the 
meshes  of  the  cellular  tissue  which  surrounds  the  uterus  and  other  pelvic 
organs.  It  is  said  to  be  more  frequent  in  "svomen  who  have  borne  nu- 
merous children,  and  in  whom  the  pelvic  tissues  are  weakened  and  the 
areolar  tissue  relaxed.  The  tumoiir  is  much  less  frequently  situated 
between  the  uterus  and  rectum.  It  may,  indeed,  be  formed  in  any  part 
of  the  pelvis  where  vessels  ramify  through  the  cellular  tissue,  and  where 
the  areolar  tissue  is  lax  enough  to  permit  separation  of  its  layers.  The 
most  frequent  site  is,  laterally,  between  the  folds  of  the  broad  ligaments. 
Here  the  vessels  are  most  numerous,  have  the  largest  calibre,  and,  being 
surrounded  by  looser  tissue  than  elsewhere,  are  less  well  supported. 
The  next  most  frequent  site  is  behind  the  uterus ;  but  inasmuch  as  the 
peritoneum  is  firmly  attached  to  the  posterior  surface  of  that  organ,  with 
very  little  intervening  areolar  tissue,  the  tumour  tends  to  run  round  and 
embrace  the  rectum,  infiltrating  the  cellular  sheath  which  gives  it  its 
mobility.  Not  infrequently  both  the  lateral  and  posterior  aspects  of  the 
uterus  are  invaded,  the  cellular  tissue  in  both  localities  being  more  or 
less  continuous.  If  the  extravasated  blood  be  considerable  and  the 
tumour  large,  the  peritoneum  will  be  separated  from  the  structures  upon 
which  it  normally  lies,  and  either  pushed  aside,  or  raised  upwards 
towards  the  cavity  of  the  abdomen,  as  in  the  cases  figured  by  Sir  James 
Simpson  and  others :  or  the  folds  of  the  broad  ligaments  may  be  sepa- 
rated, and  their  upper  borders  elevated.  The  position,  shape,  and  di- 
mensions of  the  swelling  vary  with  the  situation  of  the  vascular  rupture 
and  the  amount  of  blood  effused. 

The  blood  swellings  in  the  pelvic  cellular  tissue  —  or  haematomas  — 
as  a  rule  are  not  so  large  as  those  found  in  the  cavity  of  the  peritoneum. 
There  is  more  resistance  to  the  escape  of  blood,  or  a  sort  of  natural 
hsemostasis,  due  to  the  density  of  the  tissues  permeated ;  and,  although 
a  certain  quantity  of  lax  cellular  tissue  surrounds  the  various  pelvic 
organs,  it  is  divided  by  layers  of  pelvic  fascia  and  the  attachments  of 
the  peritoneum.  Occasionally,  however,  the  pressure  exerted  is  such 
that  the  peritoneal  layer  is  raised  quite  above  the  pelvis ;  or  the  layer 
gives  way,  and  secondary  rupture  takes  place  into  the  peritoneal  cavity. 
There  is  reason  to  believe  that  small  extravasations  of  blood  take  place 
much  more  frequently  than  was  at  one  time  supposed,  both  into  and 
outside  the  peritoneum  about  the  time  of  the  catamenial  periods.  If 
the  quantity  of  blood  be  sparing  there  may  be  no  very  well-defined 
swelling,  and  the  symptoms  being  obscure  the  diagnosis  is  difficvdt.  The 
results  of  pliysiohjgical  experiments,  as  well  as  ol)servation  in  cases  of 
laparotomy,  prove  that  small  quantities  of  l>lood  effused  into  the  cavity 
of  the  peritoneum  speedily  disappear  when  the  serous  membrane  is 
healthy.  The  case  is  quite  otherwise  when  the  peritoneum  has  been 
altered  by  inflammation,  for  its  power  of  absorption  is  then  impaired  or 
destroyed.    After  the  occurrence  of  obscure  symptoms  of  blood  effusion. 


PELVIC  ILEMATOCELE  531 


repeated,  it  may  be,  more  than  once,  the  formation  of  a  distinct  tumour 
may  indicate  that  it  is  but  the  further  development  of  mischief  which 
may  have  been  suspected  but  not  verified.  The  evidence  of  the  post- 
mortem room  also  points  to  the  fact  that  haemorrhages  both  intra-  and 
extraperitoneal  may  be  progressive. 

Sources  of  Haemorrhage.  —  The  sources  which  have  been  described 
are  somewhat  numerous  ;  and  more  extended  observation  has  multiplied 
them.  Voisin  described  only  three  causes ;  namely,  congestion  and  haemor- 
rhage from  the  vesicles  of  de  Graaf  during  a  menstrual  period ;  reflux  of 
blood  from  the  uterus  into  the  tubes  and  from  thence  into  the  peritoneum, 
and  htemorrhage  originating  in  the  Fallopian  tube  itself.  Bernutz  speaks 
of  five  sources,  and  classes  the  varieties  in  accordance  with  the  cause, 
thus — i.  Hsematocele  symptomatic  of  rupture  of  utero-tubal  varices ; 
ii.  Haematocele  symptomatic  of  bloody  exhalation  from  the  jDelvic  peri- 
toneum ;  iii.  Haematocele  symptomatic  of  rupture  of  the  ovary  or 
Fallopian  tube ;  iv.  Haematocele  symptomatic  of  difficult  menstrual 
excretion ;  v.  Haematocele  symptomatic  of  excessive  secretion  from  the 
genital  organs  —  menorrhagic  htematocele. 

More  recent  researches  have  tended  to  the  better  definition  of  the 
sources  of  haemorrhage,  while  at  the  same  time  a  larger  number  of  sources 
is  recognised.  The  evidence  concerning  some  of  the  former  supposed 
sources  of  haemorrhage  is  now  regarded  as  indistinct  and  inconclusive, 
while  the  frequency  of  others  is  sustained  by  accumulated  observation 
and  testimony. 

i.  The  most  frequent  source  of  large  extravasations  of  blood  into 
the  pelvis  is  undoubtedly  the  various  forms  of  extra-uterine  gestation,  be 
they  tubal,  ovarian,  or  other  variety.  Vigues  and  Gallard  believed  the 
rupture  of  a  tubal  pregnancy  to  be  the  cause  of  all  cases  of  intra- 
yjeritoneal  haematocele.  Mr.  Lawson  Tait  regards  ectopic  gestation  as 
almost  the  exclusive  cause,  and  likely  to  be  always  fatal  unless  operated 
upon.  It  is  to  be  noted,  however,  that  he  draws  a  broad  distinction,  in 
respect  of  danger,  between  effusions  of  blood  into  and  outside  the  peri- 
toneum, whether  due  to  extra-uterine  gestation  or  not ;  but  he  has  no 
doubt  that  a  collection  of  blood  from  this  cause,  originally  in  the  cellular 
tissue,  may  break  its  bounds  and  burst  into  the  peritoneum  in  a  secondary 
manner.  Fritsch,  in  his  Krankheiten  der  Frauen,  makes  hematocele  and 
the  bursting  of  an  extra-uterine  pregnancy  synonymous.  In  a  recent 
System  of  Gynaecology,  edited  by  Baldy,  it  is  stated,  in  accordance  with  the 
teaching  of  Lawson  Tait,  that  in  nearly  all  cases  ectopic  gestation  is  the 
cause  of  pelvic  haematocele  of  whatever  kind.  It  is  admitted  that  there 
may  be  exceptions,  but  tliey  are  rare.  This  statement  goes  too  far.  It 
does  not  accord  with  my  own  experience,  and  to  accept  it  would  be  to 
ignore  the  recorded  observations  and  opinions  of  some  of  the  best  authori- 
ties on  the  subject.  Even  when  a  tubal  pregnancy  has  been  present,  it 
may  have  been  but  the  indirect  cause  of  haematocele;  for  tlie  blood  ex- 
travasation has  occasionally  come,  not  from  rupture  of  the  ectopic  sac, 
but  from  a  dilated  vein  in  the  broad  ligament.     Effusions  of  blood  aris- 


532 


SYSTEM  OF  GYNAECOLOGY 


iug  from  the  rupture  of  au  extra-uterine  pregnancy  would,  of  course,  be 
altogether  excluded  from  the  definition  of  hsematocele  by  authors  like 
Bernutz  and  Yoisin,  who  restrict  the  term  to  cases  occurring  as  the  result 
of  some  accident  in  menstruation.  The  symptoms  are  so  exactly  parallel 
to  blood  extravasations  arising  from  other  causes,  and  sometimes  so 
absolutely  indistinguishable  from  them,  that  clinically  it  is  impossible 
to  separate  them.  The  haematocele  may  be  clearly  discernible,  but  the 
cause  wrapped  in  obscurity.  The  blood  effused  in  the  several  forms  of 
ectopic  gestation  is  sometimes  so  large  and  sudden  as  to  merit  the 
appellation  given  by  Bernutz  as  *•'  dramatic,"  or  by  Dr.  Eobert  Barnes  as 
"  cataclysmic  "  ;  and  such  cases  correspond  to  those  described  by  Voisin 
as  '^ non-encysted  ha^matocele  or  extravasation."  Occasionally  this  rupt- 
ure of  an  extra-uterine  pregnancy  takes  place  in  successive  stages,  and 
by  repeated  attacks  following  exactly  the  course  of  such  extravasations 
of  blood  from  other  causes ;  if  so  the  cases  are  most  obscure,  both  as 
to  diagnosis  and  causation.  Mr.  Bland  Sutton,  in  explaining  the  way 
in  which  sudden  and  large  extravasations  take  place  in  these  instances 
■contends  that  in  some  at  least  of  the  tubular  foetations  an  apoplexy 
occurs  in  the  membranes  surrounding  the  embryo.  Thus  an  ovum  the 
size  of  a  walnut  is  suddenly  enlarged  to  the  bulk  of  an  orange,  and  the 
tube  being  unequal  to  the  distension,  gives  way  and  rupture  occurs, 
either  into  the  peritoneum  or  into  the  broad  ligament.  Mr.  Knowsley 
Thornton  has  reported  an  instance  where  the  rupture  of  an  extra-uterine 
sac,  not  larger  than  a  hazel  nut,  gave  rise  to  fatal  hsemorrhage. 

ii.  Axjart  from  pregnancy,  the  rupture  of  a  vessel  in  some  of  the 
structures  of  the  ovary  is  a  not  infrequent  cause  of  pelvic  haematocele. 
This  does  not  mean  hsemorrhage  in  connection  with  large  ovarian 
tumours,  when  bleeding  commonly  takes  place  into  the  interior  of  cysts 
rather  than  outside  the  mass :  ovarian  cysts  are  occasionally  filled  with 
coagulated  blood,  which  has  been  poured  into  their  interior  from  the 
rupture  of  a  vessel  in  the  walls  of  the  cyst ;  and  death  has  been  known 
to  result  from  intracystic  haemorrhage  of  this  kind.  Nor  should  it  in- 
clude the  escape  of  blood  from  the  stump  of  an  ovarian  cyst  treated 
intraperitoneally,  noticed  by  Sir  Spencer  Wells;  this  is. but  an  accident 
of  the  ovarian  operation.  In  normal  conditions  it  has  been  fully  proved 
that  at  or  about  periods  which  correspond  in  the  woman  with  the 
appearance  of  the  catamenia,  one  or  more  Graafian  vesicles,  near  the 
surface  of  the  ovary,  mature,  become  distended  with  blood,  and  at  last 
rupture  to  discharge  their  contents  into  the  infundibulum  of  the 
Fallopian  tube.  Ordinarily  this  physiological  process  is  so  perfectly 
performed  that  no  blood  escapes  into  the  ])erit()neum  from  the  encir- 
cling firnbriijc,  and  little  disturbance  is  produced.  When,  however,  any 
antecedent  morbid  change  has  so  altered  the  structure  of  the  ovary  as 
to  induce  undue  hyperemia,  or  to  increase  the  size  of  its  blood-vessels, 
or  again  to  produce  such  adhesions  of  the  fimbria  as  to  interfere  with 
the  complete  grasping  of  the  ovary  during  the  act  of  ovulation,  then 
blood  may  be  effused  in  more  considerable;  (juantity.    Congestion,  chronic 


PELVIC  HEMATOCELE  533 

inflammation,  and  hypertrophy  of  the  ovary,  by  enlarging  the  calibre  of 
the  blood-vessels,  induce  a  tendency  to  unusual  haemorrhage  at  the 
period  of  ovulation ;  and  the  same  may  be  said  of  other  morbid  condi- 
tions of  the  ovary.  Voisin  arrives  at  the  conclusion  that  there  is  usually 
some  pre-existing  disease  of  the  ovary  which  disposes  to  laceration  of  the 
blood-vessels  and  consequent  extravasation ;  and  he  adduces  several 
examples  of  hsematocele  produced  in  this  way.  It  is  by  no  means  un- 
common in  the  post-mortem  room  to  find  small  collections  of  blood  in 
the  substance  of  the  ovary,  especially  when  it  is  beginning  to  undergo 
degeneration,  cystic  or  otherwise.  Small  cysts  filled  with  coagulated 
blood  are  often  found,  and  at  times  the  distension  has  been  so  great  as 
to  produce  rupture  and  extravasation  into  the  peritoneal  cavity.  This 
catastrophe  is  the  more  likely  to  occur  if  the  effects  of  accident  or  violence 
be  superadded  to  the  existing  morbid  condition.  M.  Gallard  suggests 
that,  in  some  cases,  haematocele  is  due  to  the  presence  of  an  ovule,  im- 
pregnated or  not,  which  has  missed  the  oviducts,  and  with  its  surround- 
ing blood  has  dropped  into  the  peritoneum. 

iii.  The  Fallopian  tube,  the  mucous  membrane  of  which  contributes 
to  the  menstrual  flux,  would  seem  occasionally,  when  unusual  excitement 
or  congestion  exists,  to  be  capable  of  pouring  out  so  large  a  quantity  of 
blood  as  to  produce  haematocele.  This  cause  of  haematocele  was  first 
indicated  by  Fenerly.  It  is  believed,  also,  that  if  blood  has  been  retained 
in  the  uterine  cavity  by  occlusion  of  the  os,  or  by  displacement  —  such  as 
extreme  retroflexion  of  the  womb  —  it  may  be  driven  by  uterine  contrac- 
tion along  the  oviducts  into  the  peritoneal  cavity ;  or  burst  the  tube 
and  so  form  haematocele.  Dr.  Emmet  thinks  the  regurgitative  theory 
elaborated  by  Bernutz  worth  a  passing  notice  only,  and  Dr.  ]\Ieadows 
did  not  think  the  accident  possible  in  the  ordinary  state  of  the  tubes  ;  to 
make  it  possible  they  must  be  abnormally  dilated,  and  the  contents  thus 
forced  towards  the  fimbriae.  Matthews  Duncan,  however,  held  that  blood 
might  be  driven  along  the  Fallopian  tubes  and  into  the  peritoneal  cavity 
when  there  was  no  obstruction  or  occlusion  at  the  os  uteri,  or  abnormal 
dilatation  of  the  tubes.  He  pointed  out  that  dilatation  of  the  tubes 
occurs  periodically  to  permit  the  passage  of  ova,  as  well  as  when  patho- 
logical conditions  have  led  to  a  more  permanent  state  of  dilatation  and 
patency.  Under  these  circumstances,  even  when  the  os  uteri  is  sufficiently 
pervious,  the  mechanical  arrangements  of  the  viscera  and  the  aerostatic 
mechanism  of  the  abdominal  walls  will  drive  fluid  along  the  tubes,  and 
so  favour  the  production  of  haematocele.  Trousseau  held  the  opinion 
that  a  blood  exhalation  from  the  mucous  membrane  of  the  tube  near 
the  fimbriated  extremity  might  account  for  cases  of  haematocele  where  the 
source  was  the  tube ;  and  Barnes  adds  a  group  of  probleniatical  cases 
where  hematocele  was  attributed  to  blood  driven  along  the  tubes  during 
abortion,  on  account  of  some  hindrance  to  its  flow  by  the  natural  passages. 

Operations  during  life,  as  well  as  post-mortem  observation,  afford 
strong  evidence  that  haematocele  may  be  produced  by  the  escape  of 
blood  from  the  tubes  under  certain  conditions  altogether  apart  from 


534  SYSTE.V  OF  GVX.^COLOGV 

tubal  pregnancy.  Imlach,  in  several  cases  of  laparotomy  for  liEematocele, 
found  both  tubes  distendecl  with  thick  black  blood  similar  to  that  present 
in  the  abdomen.  Dr.  Barlow  has  reported  a  case  where  the  tube  was 
distended  with  clot  protruding  from  the  outer  extremity  —  the  inner 
being  occluded ;  and  Scanzoni  has  described  a  case  in  which  a  tube  was 
distended  to  the  size  of  a  finger  and  held  two  ounces  of  blood ;  sixteen 
ounces  had  escaped  into  the  peritoneal  cavity  :  there  was  no  pregnane}'. 
Dr.  Cullingworth  has  reported  a  case  where  rupture  of  a  varicose  vein 
inside  the  Fallopian  tube  produced  haematocele.  The  haemorrhage,  taking 
place  from  the  abdominal  end  of  a  Fallopian  tube,  is  regarded  as  likely 
in  most  instances  to  be  progressive  in  its  character,  rather  than  sudden 
and  abundant ;  and  in  this  way  to  alter  the  neighbouring  peritoneum  by 
the  intercurrent  inflammation  it  produces.  Thus  it  is  inferred  that 
minor  forms  of  haematocele  may  arise,  accompanied  with  only  obscure 
pelvic  discomfort,  and  giving  little  evidence  of  tumour  until  accumulation 
has  occurred  as  the  result  of  attacks  frequently  repeated ;  then  the  altered 
peritoneum,  in  its  turn,  may  add  accretions  to  the  mass,  by  exhaling  blood 
from  its  altered  surface,  as  in  primary  haemorrhagic  pachy-peritonitis. 
These  are  probably  some  of  the  cases  in  which  adhesions  are  said  to  be 
present  before  the  formation  of  distinct  haematocele,  as  indicated  by 
Schroeder  and  by  Hart  and  Barbour,  and  in  which  an  antecedent  roof 
is  partly  formed  over  Douglas'  pouch. 

Guerin  advances  the  view  that  blood  may  regurgitate  through  the 
tubes,  as  the  result  of  membranous  dysmenorrhoea,  and  be  effused  into 
the  peritoneal  cavity.  The  mucous  membrane  of  the  uterus,  he  says, 
swells  up  so  as  to  fill  the  whole  cavity :  this  being  exfoliated  towards 
the  end  of  the  period  may  absolutely  plug  the  os  uteri ;  and  uterine  con- 
tractions, to  expel  it,  drive  blood  through  the  Fallopian  tubes  into  the 
abdominal  cavity.     Pozzi  thinks  this  explanation  quite  natural. 

iv.  Rupture  of  vessels  in  the  bulb  of  the  ovary  or  pampiniform 
plexus,  lying  between  the  folds  of  the  broad  ligament,  is  enumerated 
among  the  causes  of  haematocele  by  Puech,  Voisin,  Scanzoni,  Bandl,  and 
others.  In  certain  patients  the  veins  here,  especially  in  the  pampiniform 
plexus  as  well  as  in  the  lower  extremities  round  the  vulva  and  anus,  are 
apt  to  become  varicose.  The  varicose  condition  of  the  ovarian  venous 
plexus  is  well  delineated  by  Winckel :  he  states  that  this  varicose  con- 
dition is  frequently  met  with  in  the  post-mortem  room,  although  Scanzoni 
believes  it  to  be  a  rare  one.  In  the  varicose  condition,  which  may  be  found 
in  pregnant  and  non-pregnant  women,  the  coats  of  the  veins  are  thinned 
and  weakened,  and  are  prone  to  give  way  under  increased  pressure  from 
muscidar  efforts,  violence,  or  indeed  from  the  hyperiemia  induced  at  the 
catamenial  periods.  Winckel  has  also  shown  th;it  ])hl(;boliths  in  the  vari- 
cose veins  may  ulcerate  through  their  walls  and  so  favour  haemorrhage. 

As  the  veins  are  enclosed  in  the  areolar  tissue,  it  seems  likely  that  in 
some  cases  an  extraperitoneal  haematocele  would  be  produced  by  such 
rupture;  but  M.  Voisin  states  that  in  all  cases  of  this  kind  which  have 
been  recorded,  laceration  took  place  into  the  peritoneal  cavity,  and  the 


I 


PELVIC  HEMATOCELE 


loss  of  blood  was  so  rapid  and  profuse  that  no  time  was  allowed  for  it 
to  become  encysted,  and  immediate  death  was  the  result. 

V.  Tardieu  and  Bernutz,  with  others,  have  described  instances  of 
intraperitoneal  haematocele,  where  the  source  of  bleeding  was  the  altered 
surface  of  the  peritoneum  itself.  Virchow  explained  this  as  a  process 
similar  to  that  which  occurs  in  "  pachymeningitis  pseudo-membrosa,"  in 
which  a  like  exudation  has  been  noticed.  Bandl  gives  it  the  name  of 
''  pelvi-peritonitis  hsemorrhagica."  Dolbeau,  who  gives  his  adhesion  to 
this  theory,  asserts  that  an  immense  number  of  cases  of  retro-uterine 
hsematocele  are  produced  by  pelvic  peritonitis  of  the  haemorrhagic  form, 
and  this  explains  the  less  serious  nature  of  some  instances  as  compared 
with  those  having  a  tubal,  ovarian,  or  varicose  source  ;  as  the  bleeding  is 
then  more  oozing  in  character. 

Hart  and  Barbour  state  that  it  is  disputed  whether  inflammation 
encysting  and  limiting  the  haemorrhage  is  antecedent  or  consequent  on  it ; 
and  think  the  former  view  has  more  evidence  in  its  favour,  although 
some  cases  support  the  latter:  they  give  one  example,  recorded  by 
Lauchlan  Aitkin,  where  the  usual  physical  signs  of  retro-uterine  haemato- 
cele  were  observed  during  life  —  namely,  a  retro-uterine  tumour  bulging 
into  the  posterior  fornix  and  displacing  the  uterus  markedly  forwards 
—  on  post-mortem  examination  the  clotted  blood  was  found  without 
adhesions.  Schroeder  believed  that  peritonitis  always  precedes  the 
occurrence  of  haematocele.  Veit  says,  if  the  abdominal  cavity  be  healthy 
no  encapsulation  of  blood  occurs ;  but,  if  adhesions  be  present,  blood 
from  whatever  source  clots  on  them,  and  fresh  adhesions  are  formed 
which  create  a  new  cyst  wall.  Schroeder  was  a  capable  and  sagacious 
observer,  and  it  seems  probable  from  available  evidence  that  encysted 
haematocele  may  be  formed  either  with  or  without  pre-existing  pelvic 
adhesions.  In  the  former  case,  if  blood  be  extravasated  below  the 
adhesions,  and  a  restraining  roof  be  thus  previously  formed  for  the 
haematocele,  the  tumour  as  felt  per  vaginam  will  be  firm  and  prominent 
from  the  first.  When  there  have  been  no  pre-existing  pelvic  adhesions, 
a  longer  time  may  elapse  before  peritonitis  lighted  up  by  the  extravasa- 
tions has  formed  limitations  for  the  blood  cyst,  and  so  the  hsematocele 
may  not  be  recognisable  so  early.  The  pre-existence  of  peritonitis,  by 
impairing  the  functions  of  the  ovaries  and  tubes,  may  indirectly  dispose 
to  pelvic  lueniorrhage,  and  the  adhesions  produced  by  peritonitis  may 
furnish  it ;  but  there  are  certainly  many  cases  of  pelvic  hematocele,  even 
of  the  encysted  form,  in  which  there  has  been  no  previous  history  of 
inflammation. 

Intraperitoneal  haemorrhage  has  been  known  to  occur  as  the  result  of 
forcible  attempts  to  replace  a  distorted  or  displaced  uterus  which  has 
been  bound  down  by  pelvic  adhesions ;  and  by  other  forms  of  violent 
procedure. 

vi.  Another  source  of  intrapelvic  hemorrhage  has  been  described 
which  differs  from  the  preceding,  inasmuch  as  there  is  no  antecedent 
peritonitis;  but  blood  oozes  from  the  genital  surfaces  —  internal  and 


536  SYSTEM   OF  GYNyECOLOGY 

external  —  and  especially  from  the  surface  of  the  peritoneum.  To  this 
pathological  condition  Bernutz  gives  the  name  of  *'  metrorrhagic  haema- 
tocele."  It  may  be  associated  with  the  '•'  metrorrhagic  diathesis  "  or  with 
haemophilia;  and  it  has  been  particularly  noticed  during  the  progress  of 
eruptive  fevers  ;  Trousseau,  therefore  called  it  ''  cachectic."  Dr.  John 
Phillips  has  recorded  a  case  in  association  with  rheumatism  which  he 
regarded  as  "cachectic."  The  formation  of  htematocele  internally  is 
preceded  and  accompanied  by  excessive  catamenial  discharge  from  the 
uterus  and  vagina ;  and  it  is  presumed  that  a  simultaneous  haemorrhage 
takes  place  from  the  surface  of  the  inner  genital  canals  and  of  the  peri- 
toneum. A  diminution  of  fibrin  in  the  blood  has  been  supposed  to  favour 
this  exudation. 

Bernutz  has  collected  many  examples  under  this  head,  which  he  has 
classed  in  groups  according  to  certain  characteristics  or  differences.  Be- 
longing to  this  order  are  not  only  hsematoceles  characterised  by  some 
cachexia,  but  also  those  associated  with  anaemia  and  chlorosis,  in  which 
cases  the  blood  is  impoverished  and  thus  more  easily  escapes  from  the 
vessels.  Although  it  is  well  established,  by  reasons  previously  stated, 
that  haematocele  unassociated  with  pregnancy  takes  place  most  frequently 
at  or  about  the  time  of  the  catamenial  period,  yet  the  affection  occurs  in 
some  instances  where  the  catamenia  are  absent,  and  where  presumably 
the  function  of  evolution  is  suspended.  During  pregnane}^,  and  after 
delivery  and  abortion,  extravasation  of  blood,  both  into  and  outside 
the  peritoneum,  may  give  rise  to  a  pelvic  blood  swelling,  having  all  the 
characters  commonly  observed  in  typical  haematocele.  Examples  of  this 
kind  have  been  recorded  by  West,  Voisin,  and  Bernutz. 

Pathological  Anatomy.  —  Before  describing  the  morbid  appearances 
in  cases  of  haematocele  proper,  it  may  be  well  to  indicate  what  takes  place 
in  those  instances  where,  the  cause  being  the  same,  haemorrhage  takes 
place  so  rapidly  and  in  such  profuseness  that  no  time  is  permitted  for 
the  blood  to  become  encysted.  The  reports  of  post-mortem  examinations 
in  such  instances  are  proportionally  much  more  numerous  than  in  those 
of  encysted  haematocele,  inasmuch  as  the  former  much  more  frequently 
end  fatally.  No  better  description  is  to  be  found  in  any  author  than  that 
originally  given  by  Voisin.  He  says  '■'■  in  the  non-encysted  form  it  is 
generally  found  after  death  that  the  skin  of  the  body  is  devoid  of  colour, 
and  the  belly  tumid,  more  particularly  in  the  region  of  the  hypogastrium. 
Black  fluid  Ijlood  may  escape  in  consideral)lc  quantity  when  the  abdomen 
is  laid  open.  The  intestines  are  distended  with  gas,  and  pushed  up 
above  the  mass  of  blood  contained  in  the  pelvic  cavity.  The  abdominal 
organs  are  often  covered  with  clots,  the  intestines  stained  of  a  bluish 
colour,  and  in  one  recorded  instance  the  mesentery  was  infiltrated  with 
blood.  The  airiount  of  blood — fluid  and  coagulated  —  contained  in  the 
pelvis  and  a])dom(!n  has  repeatedly  been  found  to  be  as  much  as  four 
pounds."  Of  twenty  cases  quoted  by  Voisin  the  source  of  haemorrhage 
was  traced  in  sixteen  to  some  distinct  lesion:  in  six,  the  haemorrhage 
came  from  the  ovary;  in  four,  from  ru])turc  of  an  ovarian  varix ;  in  two, 


PELVIC  HEMATOCELE  537 

from  the  cavity  of  the  uterus  ;  and  in  four,  from  the  Fallopian  tube.  In 
the  remaining  four  no  distinct  lesion  could  be  found,  and  it  was  supposed 
that  the  haemorrhage  arose  as  an  exhalation  of  blood  from  the  surface 
of  the  peritoneum.  In  these  statistics  no  mention  is  made  of  the  rupture 
of  a  Fallopian  tube,  or  of  any  other  form  of  extra-uterine  gestation,  for 
blood  extravasations  in  association  with  pregnancy  were  excluded  by 
Voisin.  In  instances  where  such  extravasation  is  dependent  on  the 
bursting  of  a  foetal  cyst,  and  if,  as  is  frequently  the  case,  death  take  place 
speedily  from  shock  and  the  quantity  of  blood  effused,  some  trace  of  the 
embryo  may  be  found  in  the  mass  of  coagulated  blood.  It  is  to  be 
noted  that  ordinarily  in  these  cases  rupture  takes  place  early  —  about  the 
second  or  third  month ;  although  I  have  seen  such  a  rupture  as  late  as  in 
the  fourth  month.  In  the  very  early  cases  it  may  be  difficult  to  find 
traces  of  the  embryo ;  but  it  may  be  less  difficult  to  find  villi  of  the 
chorion,  either  swimming  in  the  effused  blood,  or  attached  to  the  lacera- 
tion from  which  the  blood  has  escaped.  The  presence  of  either  leaves 
no  doubt  as  to  the  cause  of  the  catastrophe.  It  must,  nevertheless,  be 
recollected  that  first  there  may  be  a  limited  haemorrhage,  which  will  form 
an  encysted  htematocele ;  and  that  this  may  be  followed  by  a  second  and 
more  abundant  haemorrhage  of  the  non-encysted  variety  which  carries  off 
the  patient.  The  post-mortem  signs  in  such  a  case  would  be  much  more 
complex  than  when  only  one  haemorrhage  had  occurred. 

As  the  subjects  of  encysted  haematocele  commonly  recover,  the  number 
of  autopsies  has  been  comparatively  few.  In  those  recorded  no  great 
tumefaction  of  the  abdomen  was  seen.  On  opening  the  abdomen  the 
general  surface  of  the  peritoneum  was  found  healthy,  except  that  ad- 
hesions were  occasionally  remarked  between  the  intestines.  If  any  of 
the  adhesions  forming  the  boundaries  of  the  cyst  had  been  torn,  or  other- 
wise broken  down,  so  as  to  allow  the  cyst  contents  to  escape  (and  these 
are  the  cases  most  likely  to  terminate  fatally),  the  usual  products  of  in- 
flammation were  found  —  more  or  less  redness  and  vascularity,  lymphy 
exudations,  purulent  serum  with  albuminous  flakes.  One  or  both 
Fallopian  tubes  have  been  found  distended  with  blood.  Sometimes  there 
have  been  indications  of  preceding  salpingitis,  and  lacerations  have  been 
detected  in  the  walls  of  the  tubes,  in  one  of  the  ovaries,  or  in  the  vessels 
of  the  broad  ligament.  Imlach  states  that  in  fifteen  cases  of  laparotomy 
for  haematocele  he  found  both  tubes  distended  Avith  black,  thick  blood. 
In  none  of  these  instances  could  there  have  been  a  question  of  tubal 
pregnancy,  or  the  distension  would  probably  have  been  limited  to  one 
side. 

To  take  a  typical  example  of  the  morbid  appearances  in  intraperi- 
toneal haematocele  from  Voisin :  "  On  a  level  with  the  brim  of  the  pelvis 
the  viscera  vv-ere  seen  to  be  united  together,  forming  the  roof  of  the  cyst. 
The  bladder  was  elevated  above  the  pubes ;  the  uterus  close  behind  it, 
somewhat  increased  in  size,  and  rotated  upon  its  axis,  in  a  position 
different  to  the  usual  one.  Behind,  adhesions  united  the  posterior  and 
superior  aspect  of  the  uterus  to  the  rectum,  a  portion  of  the  sigmoid 


538  SYSTEM  OF  GYNAECOLOGY 

flexure  of  the  colon,  and  several  coils  of  small  intestine,  the  two  broad 
ligaments,  and  the  posterior  half  of  the  circumference  of  the  brim  of  the 
pelvis.  A  roof  was  thus  formed  over  the  posterior  half  of  the  pelvic 
excavation.'  On  laying  open  the  cyst  the  thickness  of  the  walls  was 
found  to  vary  with  the  amount  of  fibrinous  exudation  at  the  point  of 
incision.  The  cyst  cavity  was  divided  into  a  number  of  compartments 
by  cellular  bands,  but  communication  existed  between  the  various  loculi. 
All  the  pelvic  organs  were  more  or  less  fixed,  the  ovaries  displaced,  and 
completely  lost  among  the  inflammatory  products.  In  an  opening  which 
had  been  effected  previous  to  the  decease  of  the  patient,  traces  of  ulcera- 
tion were  found,  and  the  fistula  between  the  aperture  and  the  cyst  was 
sinuous  and  irregular." 

The  contents  of  the  cyst  vary  with  the  date  at  which  the  blood  extrav- 
asation took  place,  and  with  other  circumstances  in  the  history  of  the  case. 
If  time  has  elapsed  after  the  blood  has  become  encysted,  it  is  usual  for 
the  contents  of  the  cavity  to  consist  of  clots  more  or  less  altered  in  colour 
and  arrangement,  sometimes  of  a  variable  quantity  of  black  fluid,  grayish 
at  certain  points,  sometimes  like  a  mixture  of  soot  and  water.  At  times 
the  fluid  has  a  tarry,  syrupy  consistence ;  and  if  suppuration  has  occurred, 
there  is  an  admixture  of  pus.  Such  products  have  been  observed  also 
when  the  cyst  has  been  evacuated  during  life.  Under  the  microscope  the 
contents  have  been  found  composed  of  blood  globules  completel}^  bereft 
of  colour,  and  so  altered  in  shape  as  to  be  scarcely  recognisable ;  besides 
these  are  fat  globules,  amorphous  particles  of  hsematoidine,  various 
crystals,  and  other  materials  resulting  from  the  transformations  of  the 
effused  blood.  In  most  cases  of  encysted  haematocele  the  displacement 
and  confusion  of  parts  is  so  great,  in  consequence  of  the  effused  blood  and 
subsequent  inflammation,  that  the  determination  of  the  source  of  haBmor- 
rhage  is  most  difficult.  From  various  data,  however,  the  blood  seems  to 
have  come  from  rupture  of  a  previously  diseased  ovary  in  the  largest 
number  of  instances. 

In  certain  cases  post-mortem  examination  has  revealed  indications  of 
attem  pts  at  spontaneous  cure.  There  have  been  solidification  and  changes 
of  colour  in  the  l>lood-clot,  absorption  of  fluid,  and  contraction  of  the  sac, 
which  is  filled  with  a  growth  of  connective  tissue  coloured  with  blood 
pigments.  These  results  have  been  observed  when  a  subsequent  attack 
of  haemorrhage  has  supervened  on  a  previous  one,  or  Avhen  the  patient 
has  succumbed  to  some  intercurrent  disease. 

Causes.  — Among  the  remoter  causes  must  first  be  mentioned  that  of 
age.  Haimatocele  occurs  during  the  period  of  greatest  sexual  vigour  in 
women.  Dr.  Tuckwell  found  that  the  decade  between  twenty  and  thirty 
years  of  age  was  the  period  of  its  most  frequent  occurrence.  According 
to  >Schroeder  tlie  largest  number  of  cases  occur  between  twenty-five  and 
thirty-five.  Out  of  forty-three  cases  twenty-seven  occurred  between 
those  ages.  Concerning  the  frequency  relative  to  other  diseases  of 
women  there  is  a  wide  diversity  of  opinion.  Thus  1  rugenberger  reported 
only  2  in  3801  cases ;  and  Scanzoni,  in  twenty-eight  years  of  practice. 


PELVIC  HEMATOCELE  539 

liacl  only  seen  eight  cases :  Olshausen,  on  the  other  hand,  places  it  as  high 
in  frequency  as  4  per  cent  of  all  female  diseases,  and  Dr.  Barnes  also 
believes  it  has  a  large  relative  frequency.  Bandl  holds  a  position  between 
the  two  extremes  of  opinion.  Marriage  seems  to  have  little  influence 
in  its  production.  Apart  from  ectopic  gestation  some  deviation  from 
normal  conditions  in  the  function  of  menstruation  has  been  noted  by  all 
observers  to  precede  the  advent  of  haematocele.  Thus  it  has  been  generally 
remarked  that  the  largest  number  of  patients  suffer  habitually  from  pro- 
fuse menstruation  —  the  colour  of  the  discharge  being  bright  and  clots 
frequent.  Voisin  remarked  that  the  greater  number  of  hematoceles 
occur  at  the  end  of  the  catamenial  period,  which  somewhat  militates 
against  his  view  that  the  habitually  profuse  menstrual  flow  observed  in 
this  class  of  patients  is  due  to  a  plethoric  condition  of  the  system,  and 
against  his  inference  that  a  recurring  over-distension  of  the  blood-vessels 
in  pletlioric  patients  favours  the  formation  of  hsematocele.  Bandl,  again, 
regards  the  frequency  of  heematocele  in  connection  with  the  monthly 
periods  as  due  to  the  high  blood  pressure  in  the  ovarian  arteries  at  those 
times  which,  having  been  weakened  by  morbid  changes,  give  way. 

Against  these  theories  it  may  be  stated  that  the  high  pressure  of  the 
arterial  circulation  is  said  to  be  greatest  at  the  beginning  of  the  function, 
not  at  the  end;  and,  again,  menstrual  haematocele  undoubtedly  occurs 
occasionally  in  feeble  and  antemic  patients  whose  menstruation  has  been 
suspended,  it  may  be  for  months ;  and  Avho  are  the  subjects  of  amenorrhoea. 
In  these  cases  the  rupture  of  an  internal  blood-vessel  does  not  necessarily 
take  place  from  any  physical  obstruction  to  the  catamenial  flow  by  the 
natural  passages,  but  from  constitutional  conditions  which  have  impaired 
the  quality  of  the  blood  and  weakened  the  integrity  of  its  containing 
walls.  In  persons  of  more  robust  health,  in  whom  blood  extravasation 
takes  place  towards  the  end  of  the  period,  the  explanation  is  probably  to  be 
found  iu  some  fault  of  ovulation,  more  particularly  iu  the  ovarian  cases. 
There  are  many  reasons  and  observations  which  point  to  the  fact  that  the 
extrusion  of  an  ovule  and  the  accompanying  rupture  of  an  ovisac  take 
place  towards  the  end  of  the  menstrual  flow,  not  at  the  beginning.  Hence 
the  greater  liability  to  attacks  of  haematocele  at  that  time. 

The  morbid  changes  in  the  blood  observed  during  the  progress  of  the 
exanthennita  and  other  fevers,  in  purpura  and  in  allied  cachectic  con- 
ditions, frequently  lead  to  attacks  of  haemorrhage  from  the  mucoiis  canals ; 
the  same  conditions  have  been  remarked  as  predisposing  causes  of  hanna- 
tocele.  Further,  it  has  been  observed  that  although  in  the  menstrual 
history  of  most  women  attacked  with  hcematocele,  the  recurrence  of  the 
periods  may  have  been  regular,  the  discharge  was  habitually  too  profuse 
and  prolonged.  Whether  abundant  or  scanty,  however,  it  was  nearly 
always  attended  with  pain,  due  either  to  obstruction  or  to  a  congested 
condition  of  the  parts  concerned.  The  cases  were  few  in  which  the  pain 
was  due  to  obstruction ;  and  in  these  there  was  either  contraction  of  the 
cervix  or  a  displaced  fundus.  In  the  rest  the  dy smenorrlireal  suffering  was 
but  the  expression  of  a  faulty  performance  of  function  in  the  generative 


540  SYSTEM   OF  GYN.-ECOLOGY 

organs,  associated  with  over-distension  of  its  blood-vessels.  Among  other 
indirect  causes  are  a  weak  and  varicose  condition  of  the  veins  in  the 
pelvis,  vulva,  and  lower  extremities.  Women  who  have  varicose  veins  of 
the  lower  "limbs  and  are  liable  to  hasmorrhoids,  to  venous  swellings  in  the 
vulva,  and  to  a  weighty,  spongy  condition  of  the  uterus,  habitually 
menstruate  too  profusely  and  painfully,  and  these  are  the  patients  most 
prone  to  hsematocele. 

The  immediate  causes  enumerated  are  sudden  suppression  of  the  cata- 
menial  flow,  over-fatigue,  violent  straining  at  stool,  cold  (especially  cold 
foot  baths  during  menstruation),  intense  mental  emotion,  premature 
exertion  after  abortion,  and  violence  producing  injury  during  menstrua- 
tion. In  a  considerable  number  of  cases  the  immediate  cause  was  traced 
to  coitus,  which  had  taken  place  either  during  the  catamenial  period  or 
shortly  after  its  termination;  and  the  pain  began  during  the  sexual 
act. 

Sjnnptoms  and  Progress.  —  There  are  three  modes  of  invasion,  and  the 
symptoms  vary  for  each  mode.  In  the  first  and  most  severe  mode, 
corresponding  to  the  non-encysted  variety  of  Voisin,  the  onset  of  the 
symptoms  is  overwhelming.  The  patient  is  abruptly  seized  Avith  severe 
abdominal  pain  and  rigor ;  these  symptoms  are  succeeded  by  utter  prostra- 
tion of  strength,  cold  extremities,  pallor  of  countenance,  which  is  anxious 
and  pinched,  and  subnormal  temperature ;  the  pulse  is  rapid  and  weak,  and 
the  general  surface  of  the  body  becomes  deadly  pale.  The  attack  may 
come  on  when  the  patient  is  apparently  in  good  health;  and  it  has  been 
suggested  that  the  suddenness  and  intensity  of  the  attack  may  possibly 
lead  to  a  suspicion  of  poisoning.  In  many  cases,  certainly,  the  symptoms 
bear  a  very  close  resemblance  to  those  produced  by  perforation  of  the 
stomach  or  other  abdominal  viscus,  with  extravasation  of  their  contents 
into  the  peritoneum ;  but  in  addition  there  is  marked  anaemia  produced 
by  sudden  and  profuse  loss  of  blood,  and  the  attack  is  often  either  co- 
incident with  a  menstrual  period  or  is  preceded  by  symptoms  of  pregnancy. 
The  belly  becomes  tender  and  hard  as  well  as  dull  on  percussion,  but 
there  may  be  no  local  tumour  observable,  as  there  has  been  no  time  for 
its  definition  by  the  formation  of  adhesions.  In  these  cases  P)ernutz 
observes,  "  we  must  be  upon  our  guard  against  too  hastily  concluding 
that  there  is  no  sanguineous  extravasation  because  there  is  no  perceptible 
hypogastric  or  retro-uterine  tumour,  or  because  the  tumour  is  slow  in 
developing  itself."  If  there  is  no  abatement  in  the  severe  symptoms, 
hiccough  and  vomiting  occur,  the  temperature  sinks  further,  and  the 
surface  of  the  skin  becomes  colder  and  more  blanched.  Syncope  or  com- 
plete collapse  speedily  follows,  with  a  sinall,  almost  imperceptible  pulse, 
and  death  generally  ensues  within  twelve  hours.  Such  sudden  and  cata- 
clysmal  symptoms  are  commonly  observed  with  the  rupture  of  a  tubular 
f)r  other  form  of  extra-uterine  ffstation.  Although  extremely  perilous 
such  cases  are  not  necessarily  fatal.  Instances  have  occurred  in  which 
the  patient  has  rallied  from  what  was  apparently  a  hopeless  condition, 
and  the  ovum   has   died  or  gone  on  developing  to  a  later  period  of 


PELVIC  JL'EMATOCELE  541 

pregnancy,  either  in  its  original  site,  or  in  some  other  locality  where  it 
had  become  lodged  after  being  extruded  at  the  time  of  rupture. 

The  second  mode  of  invasion  corresponds  with  ordinary  forms  of  en- 
cysted hsematocele,  extra-  or  intraperitoneal.  Here  the  symptoms  are  to 
some  extent  the  same  in  character  as  in  the  non-encysted  form,  but  those 
common  to  both  are  less  in  severity.  The  gravity  of  the  attack  varies 
in  accordance  with  the  suddenness  and  the  amount  of  blood  extravasa- 
tion, and  the  general  condition  of  the  patient.  The  severity  of  the 
attack  will  be  modified  by  the  seat  of  the  effused  blood  —  being  more 
acute  and  ^threatening  when  the  blood  is  poured  into  the  peritoneal 
cavity,  less  so  when  the  effusion  is  into  the  cellular  tissue  — for  the  double 
reason,  that  less  disturbance  is  provoked  when  blood  is  extravasated 
beneath  the  peritoneum  than  on  its  free  surface ;  and  that  effusion  is 
likely  to  be  sloAver  and  more  gradual  into  the  meshes  of  the  cellular 
tissue.  In  both  cases  the  first  symptoms  indicate  pain,  exhaustion,  and 
more  or  less  pronounced  collapse,  due  to  the  escape  of  blood  internally, 
and  they  are  followed  by  symptoms  of  pelvic  peritonitis.  It  has  been 
noticed  by  several  writers  that  the  amount  of  collapse  bears  no  sort  of 
relation  to  the  amount  of  blood  effused,  and  is  always  greater  in  cases  of 
intraperitoneal  hematocele  because  of  the  sensitive  surface.  Emmet  says 
he  detected  by  accident,  in  one  instance,  an  accumulation  of  blood  going  on 
in  the  peritoneal  cavity  without  the  patient  suffering  any  discomfort ;  and 
Dr.  Playfair  has  observed  an  instance  where  a  considerable  quantity  of 
blood  was  found  in  the  peritoneum,  though  there  had  been  no  antecedent 
symptoms  of  such  a  nature  as  to  indicate  its  presence.  Here,  probably, 
the  serous  membrane  had  been  altered  by  the  previous  inflammatory 
changes  surrounding  an  ovarian  tumour ;  but  such  cases  are  rare  and 
exceptional.  Commonly  the  illness  is  preceded  by  some  notable  derange- 
ment in  the  catamenial  function,  and  dates  from  a  menstrual  period, 
which  has  perhaps  been  attended  with  more  than  usual  pain,  the  dis- 
charge being  inordinately  profuse  and  prolonged  beyond  the  normal 
limits.  Then  immediately  after  some  such  effort  as  straining,  coitus,  or 
the  like,  comes  a  rigor,  with  sudden  and  intense  pain  in  the  pelvis  often 
compared  to  the  throes  of  parturition,  and  increased  by  pressure  or 
movement.  If  the  blood  effused  be  considerable  in  quantity,  and 
particularly  if  it  be  thrown  into  the  peritoneum,  there  is  fainting  almost 
amounting  to  syncope,  and  this  is  conjoined  with  signs  of  local  peri- 
tonitis. In  several  instances  it  has  been  noticed  that  the  patient,  having 
been  exposed  to  cold  or  undue  exertion  during  menstruation  or  im- 
mediately after  it,  has  awoke  in  the  night  with  a  sense  of  exhaustion  and 
faintness,  and  has  begged  to  be  supplied  with  food.  This  preliminar}^ 
exhaustion  has  speedily  been  succeeded  by  abdominal  pain  and  other 
characteristic  symptoms.  The  pain  may  be  dull  and  continuous,  or 
paroxysmal,  with  recurring  exacerbation  ;  and  a  weight  about  the  anus  is 
often  complained  of,  with  frequent  ineffectual  attempts  to  evacuate  the 
bowels.  There  is  often  tenesmus,  and  quantities  of  mucus  may  be  passed 
—  possibly  mixed  with  blood  —  indicating  irritation  of  the  intestinal  mu- 


542  SYSTEM   OF  GYN.-ECOLOGY 

cous  membrane.  Painful  micturition  is  not  infrequent,  and  partial  or 
complete  retention  of  urine  may  lead  to  complications  in  diagnosis  and 
mask  the  real  ailment.  The  patient  prefers  to  lie  upon  her  back,  with 
the  thighs  flexed  on  the  abdomen,  as  usually  observed  in  cases  of  peri- 
tonitis ;  and  there  is  often  considerable  distension  of  the  intestines  by 
flatus.  Great  nervous  disturbance  is  often  a  prominent  feature  in  these 
attacks  of  illness.  Coma  and  insensibility  are  rarely  present,  but  rather 
marked  distress  and  restlessness,  very  inimical  to  the  quietude  so 
necessary  for  the  patient,  and  severe  neuralgic  pains,  not  only  in  the 
pelvis  but  also  in  the  lower  limbs  and  elsewhere.  The  sort  of  paralysis 
of  the  intestines  of  some  patients  is  believed  by  Poncet  to  be  brought 
about  by  the  joint  effect  of  pressure  in  the  pelvis  and  the  general  nervous 
exhaustion.  Supervening  on  the  stage  of  exhaustion  or  collapse,  acute 
febrile  symptoms  speedily  develop  themselves,  with  rapid  pulse,  increase 
of  temperature,  and  loaded  urine.  To  these  symptoms  Voisin  adds  — 
as  a  very  characteristic  sign  of  the  nature  of  the  affection  —  a  rapidly 
produced  and  marked  pallor  of  the  skin,  which  assumes  a  dull  white- 
ness not  unlike  that  which  accompanies  the  cancerous  cachexia. 

The  tliird  mode  of  invasion  is  that  in  which  the  symptoms  are  devel- 
oped very  gradually  and  in  succession ;  the  case  assuming  a  chronic  form. 
Such  instances  undoubtedly  exist,  and  are  beset  with  difficulty,  as  they 
are  apt  to  be  confounded  with  other  affections.  As  previously  remarked, 
there  is  no  doubt  that  small  extravasations  of  blood  take  place  in  the 
deeper  parts  of  the  pelvis  without  forming  a  distinct  tumour,  or  being 
attended  by  very  definite  symptoms.  These  attacks  may  be  repeated 
more  than  once,  at  uncertain  intervals,  until  one  occurs  of  a  character 
so  acute  or  intense  as  to  leave  no  doubt  of  its  nature,  and  connecting 
itself  clearly  with  the  former  attacks  of  less  distinctness.  In  this  way 
there  may  be  many  varieties  both  in  reference  to  the  severity  of  the 
attack  and  the  time  of  its  recurrence ;  and  the  same  patient  may  be  the 
subject  of  the  slighter  or  graver  forms  of  the  malady.  These  repeated 
attacks  may  be  associated  with  the  various  forms  of  ectopic  gestation, 
with  the  "  haemorrhagic  peritonitis  "  before  named,  or  Avitli  intermitting 
haemorrhages  from  the  Fallopian  tubes. 

Metrorrhagia  is  one  of  the  commonest  concomitant  symptoms  of 
pelvic  hfiematocele  in  all  its  varieties.  So  large  and  continuous  in  some 
cases  is  the  loss  of  blood  by  the  natural  passages,  tliat  this  symptom 
mainly  engrosses  the  attention  of  the  medical  practitioner,  to  the  exclu- 
sion of  the  changes  taking  place  in  the  deeper  parts  of  the  pelvis. 
Metrorrhagia  is,  however,  not  always  present. 

If  the  extravasation  be  large,  and  yet  not  too  large  to  be  localised,  a 
tumour  is  soon  to  be  discovered  through  the  abdominal  walls,  above  the 
pubes,  in  the  direction  of  the  iliac  fossa  on  either  side,  or  projecting 
downwards  in  the  interior  of  the  pelvis.  Dr.  West  says  that  he  has 
detected  the  swelling  within  forty-eight  hours  after  the  first  symptoms, 
and  in  many  cases  it  may  lie  detected  earlier,  especially  if  it  be  circum- 
scribeil  Ity  previous  pelvic  adhesions  ;  although  a  certain  time  must 


PELVIC  HEMATOCELE  543 

elapse  before  the  blood  becomes  so  consolidated  as  to  be  accurately 
defined.  At  the  first  onset  of  the  attack  no  distinct  local  tumour  may 
be  detected,  though  the  abdomen  may  be  distended  by  meteorism. 
When  detected  it  is  commonly  only  somewhat  tender  to  pressure ;  but 
occasionally  careful  examination  is  rendered  impossible  for  a  time  by  the 
extreme  sensitiveness.  The  tumour  is  best  examined  as  the  patient  lies 
upon  her  back ;  as  then  external  and  internal  palpation  can  be  combined, 
and  the  most  accurate  estimate  formed  of  the  size,  consistence,  and 
relations  of  the  mass.  Exploration  by  the  vagina  and  rectum  should 
rarely  be  omitted,  as  in  this  way  the  position  of  the  swelling  between 
the  vagina  and  bowel  is  at  once  ascertained. 

In  the  physical  examination  of  the  tumour  it  is  important  to  recollect 
that  it  presents  a  succession  of  changes  in  its  density  in  accordance  with 
its  duration.  As  soon  as  it  can  be  defined  it  presents  the  characters  of 
dulness  on  percussion,  immobility,  or  very  partial  mobility,  and  more  or 
less  of  irregularity  in  outline.  Soon  after  its  formation  it  is  elastic  and 
indistinctly  fluctuating ;  later  it  is  irregular,  and  of  unequal  density  — 
the  firmness  of  its  borders  closely  resembling  the  results  of  pelvic 
cellulitis.  If  considerable  in  size,  and  retro-uterine,  it  is  found  on 
vaginal  examination  to  occupy  the  posterior  half  or  more  of  the  pelvis, 
elevating  and  pushing  forward  the  cervix  uteri  above  the  pubes,  stretch- 
ing and  pushing  down  the  posterior  wall  of  the  vagina,  and  compressing 
the  rectum  behind  it  into  the  concavity  of  the  sacrum.  In  rarer 
instances,  where  the  tumour  is  more  or  less  in  front  of  the  nterus,  the 
cervix  uteri  is  throAvn  backwards.  Chassaignac  has  reported  a  case  in 
which  the  sanguineous  effusion  was  entirely  between  the  bladder  and 
uterus,  thus  forcing  the  entire  uterus  backwards.  In  all  cases  the  tumour 
seems  fused  into  and  more  or  less  nnited  to  the  uterus.  Nevertheless 
the  uterus  may  occasionally  be  moved  in  some  degree  independently,  both 
with  the  finger  and  the  uterine  sound.  Where  the  uterus  is  pushed  up- 
ward and  forward  by  a  blood  mass  in  the  posterior  part  of  the  pelvis,  it 
may  be  traced  in  outline  by  external  and  internal  palpation;  and  the 
sound  verifies  its  position,  proving  that  the  displacement  is  not  due  to 
retroflexion.  Matthews  Duncan  noticed  that  the  length  of  the  uterine 
cavity  was  much  increased  whenever  the  haematocele  was  large,  and  that 
it  decreased  with  its  contraction.  Frequently  the  blood  tumour  has  been 
observed  of  such  dimensions  as  almost  to  fill  the  true  pelvis,  and  to 
distend  and  push  down  the  back  wall  of  the  vagina  so  far  that  it 
almost  reached  the  vulva.  Where  the  swelling  projects  very  low  in  the 
pelvis  it  has  been  supposed  that  it  must  necessarily  be  due  to  extravasa- 
tion into  the  cellular  tissue,  because  the  peritoneal  cavity  has  a  higher 
level ;  but  when  it  is  recollected  that  the  peritoneum  is  often  prolongeil 
far  down  the  posterior  Avail  of  the  vagina,  and  that  the  lower  boundary 
of  the  cul-de-sac  almost  reaches  the  floor  of  the  pelvis,  this  deduction  is 
seen  to  be  of  uncertain  value.  The  tumour  sometimes  seems  much  lower 
in  the  pelvis  than  it  really  is,  owing  to  a  large  amount  of  oedema  of  the 
recto-vaginal  septum  below  the  true  level  of  the  haematocele.     This  is 


SU  SYSTEM  OF  GYNECOLOGY 

occasionally  so  considerable  as  to  form  a  distinct  rounded  swelling 
projecting  towards  the  vagina,  and  it  is  found  also  in  some  cases  of 
cellulitis.  ■  The  bulging  of  the  tumour  downwards  is  not  universal  even 
when  blood  occupies  the  retro-uterine  cul-de-sac,  or  is  in  the  loAvest 
meshes  of  the  cellular  tissue :  the  retro-uterine  pouch  may  have  been 
unusually  shallow,  or  it  may  have  been  partially  obliterated  by  previous 
pelvic  adhesions,  as  indicated  by  Schroeder.  This  author  gives  illustra- 
tions, showing  large  collections  of  blood  in  the  pelvis,  the  lower  margin 
of  which  is  on  a  level  with  or  a  little  below  the  upper  part  of  the  sym- 
physis pubis ;  in  one  of  these  diagrams  the  true  pelvis  is  represented 
as  nearly  full  of  blood.  In  these  cases  the  finger  would  have  to  be 
carried  up  to  the  fornix  vaginee,  or  even  higher,  to  reach  the  lower 
border  of  the  tumour.  When  the  position  of  the  tumour  is  other  than 
retro-uterine  it  will  displace  the  pelvic  organs  in  accordance  with  its 
dimensions  and  relative  position.  On  more  than  one  occasion,  being 
formed  in  front  of  it,  it  has  been  stated  to  have  produced  complete  retro- 
version of  the  viterus.  Sir  James  Simpson,  Dr.  Graily  Hewitt,  and  others, 
give  illustrations  in  outline  of  the  extraperitoneal  form  or  hmmatoma  of 
some  authors.  In  one  of  Graily  Hewitt's  cases  the  haematic  tumour 
rose  as  high  as  the  crest  of  the  ilium  on  the  right  side,  and  dipped  half 
way  down  the  pelvic  canal  inferiorly.  In  the  second,  the  extravasated 
blood  is  represented  as  surrounding  the  bladder,  uterus,  and  rectum  in 
every  direction  —  as  in  Hart  and  Barbour's  diagram  —  and  the  tumour  so 
formed  reached  as  high  as  the  umbilicus  above,  and  to  within  a  short 
distance  of  the  perineum  below.  These,  however,  are  extreme  cases,  and 
it  must  be  noted  that  the  illustrations  are  diagrams,  and  do  not  profess 
to  be  pathological  drawings.  More  frequently  in  the  extraperitoneal 
form,  or  hsematoma,  the  swelling  will  only  be  felt  by  internal  examina- 
tion ;  it  will  be  distinctly  lateral  in  position,  occupying  one  of  the  broad 
ligaments,  fixing  the  uterus  much  in  the  same  way  as  in  pelvic  cellulitis, 
and,  in  many  cases,  if  seen  in  the  later  stages,  quite  indistinguishable 
from  it.  Occasionally  the  quantity  of  blood  effused  is  so  small  that,  not- 
withstanding the  presence  of  characteristic  general  symptoms,  no  well- 
defined  tumour  can  be  detected.  Drs.  West  and  Matthews  Duncan, 
who  had  noticed  the  absence  of  distinct  tumour  in  some  of  these  cases, 
inferred  that  the  extravasation  was  tooextensive  to  become  circumscribed ; 
but  there  are  certainly  instances  where  the  general  symptoms  are  very 
marked  and  characteristic,  and  yet  the  amount  of  effusion  has  been  so 
slight  as  to  produce  but  little  local  tumefaction. 

In  some  rare  cases  more  than  one  haematic  tumour  has  been  observed 
at  the  same  time;  one  situated  in  the  iliac  region,  for  example  —  felt 
l)y  external  examination  —  the  other  lying  deeply  in  the  pelvis,  and 
reached  only  by  vaginal  exploration.  It  is,  of  course,  possible  that 
these  apparf!ntly  separate  tumours  may  have  been  poles  of  one  long 
mass. 

Some  authors  have  enumerated  among  the  symptoms,  during  the 
progress  of  hsematocele,  an  undue  pulsation  of  the  arteries  in  the  vagina 


PELVIC  HyEMATOCELE  545 

and  cervix  uteri ;  but  this  is  an  uncertain  symptom,  and  in  a  case 
described  by  Dr.  Madge,  in  the  Obstetrical  Transactions,  it  was  notably 
absent,  as  was  also  the  pain  in  defaecation  so  commonly  observed. 

Among  the  occasional  symptoms  are  blood  in  the  urine ;  severe  pains 
in  the  lumbar  and  sacral  regions  and  down  the  limbs ;  oedema  of  the 
lower  extremities  and  vulva;  and,  more  rarely  still,  phlebitis  in  the 
crural  veins  produced  either  by  pressure  or  blood  poisoning.  A  still 
more  exceptional  symptom  has  been  observed  by  some  writers  in  connec- 
tion with  extraperitoneal  haematocele,  namely,  an  ecchymosed  colour  of 
the  vagina;  and  in  two  cases  ecchymosis  of  the  abdominal  wall. 

The  i^rogress  varies  very  much  with  the  age  of  the  patient,  her  con- 
dition of  health  at  the  time  of  the  seizure,  and  the  character  of  the 
attack.  Sometimes  the  attack  sets  in  with  great  violence  and  the  pro- 
gress is  rapid.  In  the  majority  of  cases  the  entire  extravasation  of  blood 
takes  place  in  a  very  short  time  from  the  commencement  of  the  attack, 
although  at  first  it  may  not  be  possible  to  define  a  tumour.  In  a  few 
hours,  however,  or  at  least  in  a  few  days,  the  swelling  is  detected,  and  it 
may  attain  the  size  of  a  child's  head,  or  of  a  gravid  uterus  at  six  months. 
When  once  formed  it  does  not  necessarily  increase  in  size  except  in  the 
cases  of  progressive  haematocele.  The  suddenness  of  its  appearance,  and 
the  rapidity  of  its  full  increase  in  size,  are  important  points  to  be 
noted  in  distinguishing  it  from  the  results  of  pelvic  cellulitis  and  other 
morbid  conditions. 

Instances  present  themselves  in  which  the  symptoms  are  less  acute. 
Blood  seems  to  be  poured  out  in  small  and  progressive  quantities  at 
certain  intervals,  creeping  on  as  it  were — the  increase  of  swelling,  in  the 
menstrual  cases  more  particularly,  corresponding  with  the  monthly 
periods.  After  the  tumour  has  attained  its  full  development — whether 
it  has  been  formed  rapidly  or  by  progressive  steps — the  natural  tendency, 
if  not  interfered  with,  is  gradually  to  decrease  in  size.  The  tumour,  at 
first  soft  and  semi-fluctuating,  becomes  harder  to  the  touch  and  of  unequal 
density,  and  the  sense  of  fluctuation  gradually  disappears.  These  altera- 
tions arise  from  the  changes  which  take  place  in  the  extravasated  blood; 
the  serum  becomes  absorbed,  while  the  coagulum  remains  and  undergoes 
the  changes  observed  elsewhere  in  blood-clots, growing  harder  and  denser. 
The  remains  of  the  clot  with  the  induration  incident  to  the  attendant 
pelvic  peritonitis  is  often  found  months  or  years  after  the  attack.  It  has 
been  noticed  by  many  authors  that  when  once  the  tumour  has  rea<;'hed 
its  full  development,  and  is  no  longer  increased  by  the  occurrence  of  the 
catamenial  period,  the  menstrual  flow  seems  to  exert  a  beneficial  etfect. 
With  each  recurring  normal  period  there  is  a  marked  decrease  in  size, 
the  improvement  taking  place  as  it  were  by  leaps  instead  of  by  gradual 
and  continuous  absorption.  Voisin,  Prof.  Dolbeau,  and  Poncet  dwell 
particularly  on  this  feature.  When  menstruation  is  present  at  the  onset 
of  the  attack  the  function  may  be  suddenly  checked,  and  only  return  after 
an  uncertain  interval.  The  rule  is,  however,  that  instead  of  being 
arrested,  it  becomes  so  profuse  as  to  be  a  marked  feature  of  the  case ; 

2n 


546  SYSTEM  OF  GYNAECOLOGY 

and  -wlien  restrained  Tvithin  moderate  limits,  often  persists  for  weeks  as  a 
further  drain  on  the  strength  of  the  patient. 

When  the  case  is  not  interfered  with  by  injudicious  surgical  pro- 
cedure, and  suitable  palliative  measures  are  adopted,  the  natural  tendency 
in  all  instances,  except  those  which  have  been  called  cataclysmic,  is  for 
the  more  formidable  symptoms  to  subside  graduall3^  The  effects  of 
shock  are  recovered  from,  the  pain  and  febrile  signs  decrease,  and  after 
a  time  the  patient  experiences  only  great  weakness,  with  a  train  of 
symptoms  more  chronic  in  character,  due  to  the  presence  of  the  mass  in 
the  pelvis,  and  more  or  less  marked  in  accordance  with  its  bulk  and 
situation.  There  may  be  a  sense  of  weight  in  the  pelvis,  bearing  down, 
some  difficulty  in  micturition  and  def  secation,  and  pain  and  discomfort  in 
attempting  to  walk  or  assume  the  sitting  posture.  If  one  side  of  the 
pelvis  be  occupied  by  the  tumour  the  nerves  and  vessels  of  the  lower 
limb  on  that  side  may  be  compressed  or  irritated,  and  pain  in  movement 
may  be  experienced  on  the  affected  side  only. 

As  a  rule,  therefore,  recovery  takes  place  slowly,  by  resolution ;  the 
blood  and  surrounding  adhesions  are  gradually  absorbed,  and  the  damage 
done  is  ultimately  repaired.  This  holds  good  even  in  the  larger  forms  of 
haematocele,  if  let  alone;  supposing  always  that  the  blood  mass  is  safely 
surrounded  by  limiting  adhesions.  In  twenty-five  cases  noted  by  Voisin 
fifteen  terminated  by  absorption.  The  average  duration  is  found  to  be 
about  four  months.  Braun,  in  twenty-four  cases,  noticed  absorption 
to  be  complete  in  six  months,  and  Bandl's  figures  point  in  the  same 
direction ;  but  one  of  his  cases  took  six  and  another  eight  months  to 
recover. 

As  in  cases  of  cellulitis  the  recovery  is  sometimes  a  very  slow  one, 
and  subject  to  many  interruptions.  The  function  of  the  pelvic  organs 
may  remain  impaired  for  months  or  years  after  the  attack,  with  indica- 
tions of  thickening  around  them,  or  perhaps  of  salpingitis  or  other  affec- 
tion of  the  tubes. 

In  a  small  proportion  of  patients  suffering  from  hsematocele,  recovery 
does  not  take  place  by  resolution,  as  in  the  more  favourable  cases,  but 
suppuration  occurs  in  the  blood-cyst.  The  contents  may  then  be 
evacuated  by  one  of  the  pelvic  canals.  There  is  a  divergence  of  opinion 
whether  suppuration  always  precedes  the  evacuation  of  the  cyst.  The 
failure  to  detect  pus  in  the  discharges  has  been  thought  to  indicate  that 
simple  ulceration  of  the  containing  walls  may  sometimes  account  for  the 
evacuation,  without  any  preceding  suppuration.  When  suppuration  does 
take  place  there  is  usually  a  reaccession  of  febrile  symptoms,  often  pre- 
ceded by  rigors  and  attended  by  rise  of  temperature  and  profuse  perspira- 
tion. If  spontaneous  evacuation  occur,  the  patient  passes  a  quantity 
of  fluid  and  semi-solid  material,  which  in  appearance  has  been  compared 
to  currant  jelly,  and  in  odour  to  decaying  flowers.  In  twenty-seven  in- 
stances, cited  by  Voisin,  six  emptied  themselves  by  the  rectum,  three  by 
the  vagina,  and  four  burst  into  the  cavity  of  the  peritoneum.  This  last 
mode  of  termination  fsaid  by  Vozzi  to  be  rare,  whether  produced  by 


PELVIC  H.EMATOCELE  547 

suppuration  or  not)  is  by  far  the  most  perilous,  inasmuch  as  it  is  uni- 
formly followed  by  general  peritonitis  and  death.  The  danger  of  rupt- 
ure into  the  peritoneal  cavity  is  always  increased  by  the  occurrence  of 
suppuration ;  hence  the  necessity  of  early  artificial  opening  when  once 
the  fact  of  suppuration  is  beyond  doubt.  Bandl  states  that  the  most 
frequent  exit  in  spontaneous  evacuation  is  by  the  rectum,  and  this  is 
not  devoid  of  danger  as  it  may  set  up  exhausting  diarrhoea.  The  open- 
ing not  being  in  the  most  dependent  part  of  the  cyst,  faecal  matter  may 
find  entrance,  foul  gases  be  formed,  and  septic  materials  generated  which 
infect  the  whole  system.  These  results  are  accentuated  if  more  than 
one  opening  occur,  and  these  may  be  into  the  rectum  and  vagina  at  the 
same  time.  When  no  general  septic  infection  occurs  the  patient  may 
be  worn  out  by  diarrhoea,  persistent  high  temperature,  impaired  nutri- 
tion, and  exhausting  sweats. 

Matthews  Duncan  dwelt  on  the  importance  of  recognising  the  exist- 
ence of  fluid  in  the  lowest  part  of  the  sac,  in  haematocele  of  some  stand- 
ing, as  indicative  of  the  presence  of  pus.  He  modified  his  opinion  later, 
and  taught  that  the  mere  presence  of  fluctuation,  unless  preceded  by 
general  and  local  signs  of  suppuration,  is  not  sufficiently  trustworthy, 
and  is  apt  to  lead  to  an  erroneous  conclusion.  The  secondary  inflam- 
mation and  suppuration  of  a  heematocele,  particularly  if  the  indications 
of  suppuration  are  so  indistinct  that  artificial  evacuation  cannot  be 
resorted  to,  may  protract  the  recovery  of  a  patient  indefinitely.  The 
formation  of  purulent  matter  at  times  takes  place  so  insidiously  that  the 
first  distiuct  proof  of  its  existence  is  the  discharge  of  pus  and  broken 
down  coagula  or  coffee-ground-like  material  by  the  rectum.  M'Clintock 
gives  an  example  of  a  patient  dying  from  a  persistence  of  these  exhaust- 
ing discharges,  and  Madge  a  case  in  which  a  woman  died  from  the  com- 
bined effect  of  exhausting  discharges  and  phlegmasia  dolens. 

Further,  it  appears  that  intercurrent  peritonitis  may  complicate  the 
progress  of  hasmatocele,  and  this  apart  from  the  rupture  of  the  cyst. 
By  this  is  meant  that,  after  the  first  inflammatory  action  has  subsided 
which  formed  the  boundaries  of  the  original  blood-cyst,  peritonitis  more 
or  less  severe  in  character  supervenes  at  times  from  slight  causes  during 
the  progress  of  the  case.  These  attacks  may  be  severe  or  slight  —  gen- 
eral or  partial  in  character :  in  all  cases  they  entail  further  peril ;  and 
at  no  time  during  the  persistence  of  the  haematocele  is  there  an  immu- 
nity from  their  reappearance.  Voisin  observed  this  mode  of  fatal 
termination  in  one  case  as  late  as  three  months,  and  another  at  the  end 
of  four  months  after  the  date  of  the  original  attack. 

Diagnosis.  —  The  points  of  distinction  between  haematocele  and  other 
morbid  conditions  found  in  the  female  pehis  recpiire  very  careful  study. 
In  an  ordinary  case  there  may  be  no  great  ditficulty;  but  it  should  be 
borne  in  mind  that  mere  physical  examination,  without  careful  investi- 
gation into  the  history  of  the  invasion,  and  a  review  of  all  the  subjective 
symptoms,  is  not  sufficient. 

i.  A  suspension  of  the  catamenia  for  one  or  more  periods  when  they 


548  SYSTEM   OF  GYNECOLOGY 

have  been  heretofore  regular,  and  symptomatic  changes  in  the  mammse 
Avith  other  signs  of  pregnancy  previous  to  an  attaclv,  may  point  to  the 
rupture  of  a- tubular  or  other  form  of  extra-uterine  pregnancy.  Such 
cases  are  generally  attended  by  ver}^  grave  symptoms,  as  ordinarily  the 
extravasation  of  blood  into  the  peritoneum  is  so  large  that  there  is  no 
opportunity  for  its  limitation  by  adhesions,  and  the  patient  speedily  dies 
from  shock  and  peritonitis.  And  the  cause  of  the  catastrophe  in  these 
cases  is  not  ahvaj's  easily  ascertained.  Such  eminent  authorities  as 
Robert  and  Hugier  both  acknowledge  that  they  have  mistaken  a  blood 
extravasation  produced  by  rupture  of  an  extra-uterine  fcetation,  and 
occupying  a  considerable  space  in  the  pelvis  and  abdomen,  for  pelvic 
hgematocele  arising  from  other  causes.  Death  does  not  necessarily  occur 
in  all  these  instances.  The  effused  blood,  if  not  too  extensive,  may, 
together  Avith  the  ovum,  become  surrounded  by  adhesions  as  in  other 
forms  of  hsematocele ;  and  either  be  absorbed,  or,  if  the  ovum  retain  its 
vitality,  continue  its  development  in  its  new  nidus.  Possibly  before 
the  sudden  invasion  of  illness  a  swelling  may  have  been  detected  in 
process  of  extension  on  the  lateral  margin  of  the  uterus.  This  with 
signs  of  early  pregnancy  clearly  point  to  ectopic  gestation. 

ii.  The  affections  which  of  all  others  bear  the  closest  resemblance  to 
pelvic  hsematocele  in  its  chronic  stages,  and  are  most  likely  to  be  mis- 
taken for  it,  are  the  various  forms  of  pelvic  cellulitis,  pelvic  peritonitis, 
and  the  after  stage  of  pelvic  abscess.  The  formation  of  a  correct  opinion 
is  often  most  difficult ;  and,  at  some  stages,  without  the  aid  of  a  suc- 
cinct history  which  is  not  always  forthcoming,  well-nigh  impossible. 
Even  with  a  clear  history  the  differential  diagnosis  is  frequently  by  no 
means  easy.  It  may  aid  discrimination  to  remember  that  attacks  of 
pelvic  cellulitis  are  more  frequent  than  haematocele.  Pelvic  inflam- 
mation and  abscess  are  more  frequently  consecutive  to  abortion  and 
delivery;  or,  when  not  so,  have  generally  some  relation  to  a  previously 
existing  inflammatory  condition  in  the  uterus  or  ovaries :  they  are  not 
generally  accompanied  with  menorrhagia,  they  are  not  attended  by 
rapidly  produced  pallor  of  the  skin  and  aufemia,  and  the  swelling,  if 
watched  throughout  its  course,  is  more  likely  to  begin  in  the  lateral  and 
deeper  parts  of  the  pelvis,  is  comparatively  slow  in  formation,  and  is 
hard  from  the  first.  If  suppuration  occur,  it  becomes  soft  and  fluctuat- 
ing later.  Hematocele,  again,  is  more  commonly  connected  with  some 
accident  of  menstruation,  and  reaches  its  greatest  intensity  suddenly ; 
the  tumefaction  is  more  frequently  behind  the  uterus ;  it  is  soft  in  its 
early  stages,  and  grows  harder  as  time  passes  on,  beginning  to  fluctuate 
again  if  the  cyst  inflames  and  suppurates. 

A  further  point  of  difference  is  that,  in  hsematocele,  if  the  swelling  be 
at  all  considerable,  it  is  more  or  less  rounded  in  form,  with  hard  inflam- 
matory margins ;  and  it  displaces  the  uterus  in  accordance  with  the 
position  of  the  blood  swelling,  but  commonly  forwards  in  the  intraperi- 
toneal form,  with  the  neck  carried  high  above  the  pidies.  In  pelvic 
inflammation,   properly  so  called,  the   fibrinous    deposit  is  infiltrated 


PELVIC  HEMATOCELE  549 

through  the  pelvic  tissues  affected,  fixing  the  uterus  more  or  less  in  its 
normal  position  so  that  it  cannot  be  elevated  or  depressed.  When 
cellulitis  is  extensive  it  fixes  all  the  viscera  in  the  pelvis  to  the  osseous 
boundaries,  as  if  plaster  of  Paris  had  been  poured  into  the  pelvis  and 
had  hardened  there.  Again,  the  constitutional  symptoms  follow  an 
inverse  order  in  the  two  affections  —  febrile  disturbance  distinctly  pre- 
cedes the  formation  of  tumour  in  the  inflammatory  affection,  it  follows 
it  in  haematocele. 

These  distinctions  refer  more  particularly  to  the  early  or  acute  stages 
of  the  affection.  When  a  case  is  seen  for  the  first  time  in  the  chronic 
stage  —  that  is,  a  considerable  time  after  the  supervention  of  the  original 
attack  —  it  may  be  more  difficult  to  determine  its  true  nature.  The 
presence  of  tumour  or  thickening  in  the  pelvis  may,  of  course,  be  due 
either  to  previous  cellulitis  or  peritonitis  ;  or  it  may  primarily  have  its 
origin  in  an  extravasation  of  blood  upon  which  inflammatory  action  has 
supervened.  It  is  only  by  a  careful  study  of  the  history  of  the  attack 
that  the  difficulty  can  be  solved.  It  may  be  equally  difficult  to  deter- 
mine, when  a  patient  is  not  seen  until  suppuration  has  occurred,  whether 
abscess  be  the  result  of  primary  phlegmonous  inflammation  or  be  the 
secondary  product  of  a  suppurating  hsematocele.  Fortunately  the  treat- 
ment in  the  two  cases  is  practically  the  same,  and  the  patient  suffers 
no  disadvantage  from  a  failure  to  decide  concerning  these  perplexing 
difficulties. 

iii.  Voisin  and  others  have  stated  that  the  diagnosis  between  hasma- 
tocele  and  inflammation  of  the  ovary  with  its  products  is  often  very 
difficult.  The  degree  of  difficulty  will  vary,  of  course,  with  the  stages 
at  which  the  patient  comes  under  observation  ;  but  ordinarily  there  will 
be  no  great  difficulty  in  discriminating  between  the  two.  The  points  of 
difference  are  the  limitation  of  pain  and  swelling,  in  the  earlier  stages 
of  ovaritis,  to  the  locality  of  one  or  other  ovary,  and  a  certain  amount 
of  febrile  disturbance  in  the  incipient  stage. 

When  a  considerable  swelling  has  formed  as  a  consequence  of  a  long 
and  intense  attack  of  ovaritis,  which  has  extended  to  siirrounding  parts 
and  become  complicated  with  pelvic  cellulitis  and  peritonitis,  it  should 
be  noted  that  there  has  been  no  sudden  invasion  or  rapid  formation  of 
a  tumour,  as  in  hasmatocele  ;  no  sudden  anaemia;  perhaps  no  coincident 
menorrhagia ;  and  the  symptoms  gradually  increase  in  severity  from  the 
commencement,  while  in  hcematocele  the  most  severe  symptoms  appear 
from  the  first,  and  as  time  passes,  undergo  gradual  amelioration. 

iv.  The  various  forms  of  uterine  and  ovarian  tumour  of  limited  size, 
beyond  the  remote  resemblance  on  ph^'sical  examination,  would  seem  to 
have  very  little  in  common  with  haematocele.  Yet  Asch  reports  a  case 
Avhere  a  supposed  hsematocele  was  punctured  through  the  vagina,  and 
was  found  to  be  an  ovarian  cyst  which  was  afterwards  successfully  re- 
moved. Tumours  are  to  be  distinguished  by  the  absence  of  urgent  sym^v 
toms  from  the  commencement,  by  their  slower  growth,  circumscribed 
form,  and  generally  by  their  mobility.     An  ovarian  tumour  is  commonly 


550  SYSTEM   OF  GYNECOLOGY 

lateral  in  position,  and,  if  it  sinks  into  the  iiterine  cul-de-sac,  it  is  rarely, 
as  3I'Clintock  lias  pointed  out,  so  low  as  blood  gravitating  there  from 
the  peritoneal  cavity.  A  more  perplexing  situation  arises  if  an  ovarian 
cyst,  prolapsed  behind  the  uterus,  inflames  and  suppurates,  or  possibly 
ruptures  there.  Inflammation  of  the  cyst,  Avhich  does  not  proceed  to 
suppuration,  may  throw  out  lymph  deposits  which  mask  the  rounded 
form  of  the  original  tumour,  and  thus  the  softer  centre  with  harder 
margins  may  simulate  the  physical  characters  of  hsematocele.  The 
diagnosis  might  be  still  more  obscui-ed  by  oedema  of  the  recto-vaginal 
septum,  which,  when  inflammatory  action  goes  on  in  the  posterior  cul- 
de-sac,  may  at  any  time  thrust  forward  the  posterior  wall  of  the  vagina, 
and  lead  to  a  sense  of  fluctuation  there.  The  only  way  out  of  these 
difficulties  is  to  study  the  history  carefully  and  to  watch  the  progress  of 
the  case.  In  the  lapse  of  time,  as  inflammatory  action  subsides,  it  may 
be  observed  that  the  serous  and  lymphy  effusions  are  absorbed,  while  the 
central  tumour  remains.  If  this  is  fluctuating  and  unattended  with  con- 
stitutional signs  of  suppuration,  it  is  pretty  certain  to  be  ovarian.  If 
suppuration  take  place  in  an  ovarian  cyst  so  placed  it  is  usually,  but  not 
always,  attended  by  characteristic  constitutional  signs.  In  all  doubtful 
cases,  where  it  is  of  importance  to  ascertain  the  true  nature  of  the  fluct- 
uating swelling,  recourse  may  be  had  to  an  exploring  needle  or  aspirator 
as  recommended  by  Sir  James  Simpson  and  Professor  Braun. 

Sudden  and  profuse  haemorrhage  into  the  cavity  of  a  large  ovarian 
cyst  may  be  attended  by  some  of  the  general  symptoms  of  hsematocele. 
There  would  be  the  indications  of  mternal  hsemorrhage  in  both  cases, 
with  the  production  of  rapid  anaemia.  Fortunately  such  cases  are  not 
frequent,  as  the  distension  of  ovarian  cysts  by  other  contents  exerts  a 
restraining  influence  against  large  blood  extravasations  into  them.  Still, 
as  before  mentioned,  death  has  resulted  from  this  cause  and  the  diagnosis 
may  be  difficult.  In  the  ovarian  haemorrhage  there  would  probably  be 
the  history  of  a  previously  existing  tumour  ;  and  the  uniformity  and 
smoothness  of  its  surface  and  the  absence  of  swelling  in  the  recto-uterine 
pouch,  should  lead  to  a  correct  conclusion. 

Fibrous  tumours  of  the  uterus,  as  a  rule,  bear  no  sort  of  resem- 
blance to  haematocele,  either  in  their  history  or  physical  characters ; 
but  seeing  that  such  experts  as  Malgaine  and  Stoltz  have  mistaken 
them  for  htematocele,  it  may  be  well  to  say  a  word  or  two  on 
the  differences.  Malgaine  and  Stoltz  both  attempted  to  remove 
tumours,  supposed  to  be  fibroids  of  the  uterus,  which  proved  to  be  retro- 
uterine htematoceles,  and  both  cases  ended  fatally.  Beyond  the  fact 
that  the  two  affections  are  commonly  attended  with  hemorrhage  there 
are  not  many  points  of  similarity.  Fibroids  of  the  uterus  are  distin- 
guished by  their  history  of  slow,  painless  growth,  by  their  density,  by 
their  position,  and  by  their  attachments  to  the  uterus.  There  is  no 
sudden  production  of  anaemia.  Yet  uterine  fibroids,  particularly  if  situated 
behind  the  utei'us,  may  give  rise  to  sudden  attacks  of  pain  arising  from 
inflammation  ;  and  the  difficulty  of  determining  whether  a  pelvic  tumour 


PELVIC  H.'EMATOCELE  551 

is  solid  or  has  fluid  contents  should  not  be  underrated.  A  distended 
l^elvic  cyst  may  feel  so  hard  and  dense  as  to  simulate  solid  growth ;  a 
fibroid,  on  the  other  hand,  may  be  so  soft,  particularly  if  previously  in- 
flamed, that  it  may  seem  to  have  fluid  contents.  The  only  way  of  mak- 
ing an  accurate  differential  diagnosis  in  doubtful  cases  of  this  nature  is 
by  the  use  of  the  aspirator  or  exploring  needle. 

Of  malignant  growths  in  the  pelvis  probably  only  encephaloid  tumours, 
which  are  rare,  run  any  chance  of  being  mistaken  for  hsematocele.  As 
they  may  be  attended  with  the  general  aspect  and  pallor  so  constantly 
observed  in  heematocele,  there  is  a  possibility  of  error ;  but  the  gradual 
development  of  the  malignant  growth,  and  the  supervention  of  anaemia 
and  waxiness  in  the  skin,  with  other  indications  of  the  cancerous  ca- 
chexia, in  the  later  rather  than  in  the  earlier  stages  of  the  affection, 
would  be  sufficient  distinctions.  Dr.  Playfair  has  recorded  an  instance 
where  hsematocele  Avas  produced  by  the  bleeding  of  malignant  growths 
in  the  peritoneum,  and  became  one  of  its  secondary  complications,  in- 
creasing the  difficulty  of  diagnosis. 

V.  Ketroflexion  and  retroversion  of  the  gravid  uterus,  j^articularly 
those  forms  in  which  the  symptoms  appear  suddenly  from  violent  efforts 
or  accident,  are  said  to  have  been  occasionally  mistaken  for  haematocele. 
The  cervix  uteri  in  both  cases  may  be  so  displaced  upwards  and  forwards 
as  almost  to  be  out  of  reach  of  the  finger ;  and  when  there  is  a  suspicion 
of  pregnancy  the  somid  cannot  in  prudence  be  used  to  aid  diagnosis.  To 
arrive  at  a  correct  conclusion  it  will  probably  be  enough  to  note  that, 
in  the  case  of  a  displaced  gravid  uterus,  there  has  been  a  suspension 
of  menstruation,  characteristic  changes  in  the  breasts,  and  other  symp- 
toms of  pregnancy;  the  retro-uterine  tumour  is  circumscribed  and 
smooth,  without  hard  adhesions  on  its  borders ;  the  cervix  uteri  has  a 
partial  mobility,  and  can  be  traced  backward  to  the  swelling  behind, 
while  there  is  an  absence  of  all  tumour  above  the  pubes.  In  some 
instances  the  fundus  may  be  raised  up  with  the  finger  in  the  posterior 
vaginal  fornix  or  in  the  rectum.  On  the  other  hand,  whenever  hematocele 
is  of  considerable  size,  it  can  probably  be  felt  above  the  pubes,  and  the 
whole  uterus  can  be  traced  lying  in  front  of  it.  The  value  of  signs 
connected  with  the  mobility  of  the  womb,  empty  or  gravid,  would  neces- 
sarily be  vitiated  where  old  adhesions  bind  it  backwards,  and  perhaps 
make  the  outline  of  the  fundus  irregular  from  the  deposits  about  it.  In 
the  unimpregnated  uterus  the  use  of  the  sound  would  show  the  direction 
of  the  uterine  cavity  and  the  position  of  the  fundus.  In  the  gravid 
organ  the  history,  more  particularly  the  early  symptoms  of  pregnancy, 
would  in  most  instances  be  sufficient  to  indicate  the  nature  of  the  case. 

vi.  FtEcal  accumulations  in  the  rectum  are  to  be  distinguished  from 
hgematocele  by  noting  that  ordinarily  they  can  be  indented  by  the  finger 
pressing  through  the  vaginal  wall.  If  harder,  a  digital  exploration  of 
the  rectum  will  reveal  their  true  nature. 

vii.  The  difficulty  in  distinguishing  between  the  intraperitoneal 
form  of  htematocele  and  the  extraperitoneal  (haematoma  of  authors)  is 


552  SYSTEM  OF  GYNAECOLOGY 

admitted.  Frankenhauser  and  Bandl  suggest,  as  a  solution,  the  placing 
of  the  patient  in  the  knee-chest  position  before  the  blood  becomes  cap- 
sulated  by  adhesions ;  then,  if  in  the  peritoneum,  it  will  flow  out  of 
Douglas'  space,  and  return  again  when  the  patient  assumes  the  dorsal 
position.  Posture  would  not  affect  the  heematoma.  This  is  a  test 
which  must  have  a  very  limited  application,  and  is  scarcely  to  be  recom- 
mended ;  for  besides  the  difficulty  of  attempting  it  with  a  patient  in 
a  state  of  collapse,  it  would  tend  to  prevent  the  desired  encapsulation 
of  the  effused  blood,  and  extend  the  peritonitis.  The  points  to  be  noted 
are  the  more  usual  lateral  position  in  haematoma  —  displacing  the  ute- 
rus to  the  opposite  side ;  the  bulging  round  the  uterus,  not  confined 
to  the  pouch  behind;  the  less  degree  of  shock  and  collapse  than  in 
intraperitoneal  hsematocele,  and  the  delay  of  the  inflammation.  The 
mass  is  unlikely  to  be  so  large  as  to  displace  the  uterus  upwards  and 
forwards  as  it  does  when  the  haemorrhage  is  intraperitoneal. 

viii.  Serous  effusion  into  the  pelvic  cellular  tissue,  associated  with 
some  of  the  low  forms  of  pelvic  inflammation,  may  be  a  farther  source 
of  confusion  in  diagnosis.  Crede  of  Leipzig  tapped  a  tumour  of 
uncertain  origin  and  got  serum  first,  then  blood-stained  serum,  and 
finally  blood.  If  the  swelling  fluctuate,  only  the  history  and  use  of  an 
aspirator  can  clear  up  its  nature.  Sir  James  Simpson  and  Sir  John 
Williams  have  both  noted  this  serous  effusion  in  the  pelvic  cellular 
tissue,  and  it  was  pointed  out  as  a  source  of  fallacy  by  myself  in  the 
article  "  Haematocele  "  in  Reynolds'  System  of  Medicine. 

The  prognosis  depends  much  upon  the  extent  of  the  haemorrhage 
and  the  gravity  of  the  attendant  symptoms  in  particular  cases.  In  the 
majority  of  instances,  if  the  right  treatment  be  adopted,  and,  the  medical 
man  can  be  persuaded  to  abstain  from  hurtful  surgical  interference, 
the  prognosis  is  favourable.  Dr.  F.  Weber  of  Berlin,  a  careful  writer 
on  this  subject,  states  that  of  twenty-three  cases  observed  by  him  none 
were  fatal,  —  a  result  he  ascribes  to  his  method  of  treatment,  which  is 
the  application  of  an  ice  bladder,  perchloride  of  iron  internally,  and  avoid- 
ance of  puncture.  Foncet,  again,  is  emphatic  in  holding  that  recovery 
is  the  rule  if  no  surgical  interference  be  practised.  These  authors  would 
probably,  however,  except  cases  where  blood  extravasation  is  so  large  as 
not  to  become  encysted,  and  also  ruptures  of  ectopic  pregnancies.  In 
all  cases  there  must  be  a  degree  of  uncertainty;  for  when  vascular 
rupture  has  taken  place  in  the  pelvis,  it  is  impossible  to  foresee  to  what 
amount  the  haemorrhage  may  extend ;  or,  when  once  apparently  checked, 
whether  there  shall  be  a  renewal  to  a  fatal  amount.  There  are,  besides, 
the  dangers  arising  from  subsequent  peritonitis,  which  may  overwhelm  a 
feeble  patient ;  and  fi-om  the  liability  to  low  forms  of  chronic  peritonitis, 
creeping  on  in  patients  not  seemingly  in  immediate  peril,  with  a  tendency 
to  aggravation  at  the  catainenial  periods.  To  these  may  be  added  the 
drain  upon  the  strength  when  a  cyst  snppui-atos  and  discharges  through 
the  bowel  or  vagina.  The  incessant  diarrhcjea  and  hectic  so  set  up  not 
uniVfujuently  have  exhausted  the  vitality  of  a  patient  who  has  survived  a 


PELVIC  HEMATOCELE 


553 


primary  attack ;  and,  if  the  contents  of  the  intestine  get  into  the  sac, 
they  may  favour  the  absorption  of  septic  materials  and  general  blood 
poisoning.  Again  a  suppurating  cyst  may  burst  into  the  peritoneum, 
and  speedily  be  followed  by  a  fatal  result.  Lastly,  if  a  patient  escape 
the  effects  of  the  original  attack,  and  also  the  risks  of  suppuration,  slie 
is  apt  to  be  long  in  a  condition  of  incomplete  recovery  with  the  pelvic 
organs  more  or  less  fixed,  the  tubes  and  ovaries  possibly  occluded,  and  a 
certain  amount  of  hardness  from  deposit  surrounding  the  uterus.  The 
chronic  persistence  of  this  deposit,  while  it  lasts,  not  only  may  inter- 
fere with  the  normal  function  of  menstruation,  but  be  a  permanent 
cause  of  sterility.  It  must,  nevertheless,  be  repeated  that  the  general 
tendency  is  towards  recovery,  if  the  effects  of  the  primary  attack  are 
surmounted ;  also  that  the  absorption  of  the  products  left  behind  may 
be  complete. 

Treatment  may  be  considered  first  as  preventive  or  prophylactic,  and 
therapeutic  or  actual  when  once  an  attack  has  occurred.  The  therapeutic 
treatment  may  again  be  divided  into  treatment  of  the  primary  attack 
and  the  treatment  of  its  consequences. 

The  prophylactic  treatment  consists  in  guarding  those  who  may  be 
most  liable  to  haematocele  from  the  exciting  causes  of  its  development. 
The  women  of  some  families  seem  more  prone  to  it  than  others ;  and 
therefore,  if  one  member  has  suffered  in  this  way,  her  sisters  should 
take  precautions,  more  especially  if  liable  to  certain  symptoms  which 
seem  associated  with  its  production.  Thus  women  who  suffer  from 
dysmenorrhoea,  particularly  in  the  congestive  form ;  or  in  whom,  from 
any  obstruction,  the  escape  of  the  inenstrual  flow  is  difficult,  should  be 
warned  to  observe  rest  and  the  recumbent  posture  during  the  catame- 
nial  period.  In  the  intervals  they  should  be  submitted,  if  practicable, 
to  treatment  of  the  painful  and  difficult  menstruation.  Women  who 
have  varicose  veins  of  the  lower  extremities,  of  the  vulva,  or  of  the 
rectum,  in  the  form  of  lu'emorrhoids,  and  the  like,  and  who  menstnuite 
therewith  painfully  and  with  abnormal  profuseness,  should  likewise  keep 
the  recumbent  position  during  the  periods,  and  avoid  all  the  causes  which 
have  been  known  to  provoke  hematocele.  Particularl}'  they  should 
avoid  travelling,  over-exertion  or  exposure  to  cold  during  menstruation ; 
coitus  should  be  interdicted  altogether  near  the  catamenial  period,  and 
<',t  other  times  practised  moderately  and  Avithout  violence. 

When  an  attack  has  occurred,  the  medical  man  will  in  the  first  place 
have  to  treat  the  patient  in  the  stage  of  shock,  and  in  doing  so  will 
have  to  consider  the  pathological  cause.  The  object  should  bo  to  palliate 
the  symptoms  of  collapse,  and  to  restore  the  depressed  vitality  of  the 
patient  without  doing  anything  which  would  tend  to  increase  the  extrav- 
asation of  blood.  Non-encysted  extravasations,  whether  arising  from 
the  rupture  of  an  extra-uterine  foetation  or  from  some  other  cause,  are 
as  a  rule  so  speedily  and  certainly  fatal  that  all  palliative  treatment  is 
likely  to  be  useless,  and  the  question  of  laparotomy  pushes  itself  inevi- 
tably to  the  front.     This  will  be  discussed  later.     Since,  however,  there 


554  SYSTEM  OF  GYNAECOLOGY 

are  at  first  no  means  of  accurately  ascertaining  the  extent  of  the  blood 
effusion  —  either  at  the  moment  or  prospectively  —  nor  the  probability 
of  its  becoming  encysted,  the  rational  plan  of  treatment  consists  in  sus- 
taining the  strength  of  the  patient,  relieving  the  pain,  and  adopting 
such  measures  as  are  likely  to  stay  the  flow  of  blood,  to  promote  its 
coagulation,  and  to  limit  it  in  such  fashion  that  it  may  become  encysted 
by  subsequent  adhesions.  These  general  indications  apply  both  to  the 
extra-  and  intraperitoneal  forms,  but  are  the  more  urgent  in  the  latter. 

The  first  thing,  therefore,  is  to  ensure  at  once  absolute  repose  in  the 
recumbent  posture,  to  impress  upon  the  patient  the  importance  of 
restraining  restlessness  and  impatient  movements  and  of  avoiding  all 
mental  emotion  or  other  disturbance  of  the  general  circulation.  A  full 
dose  of  opium  or  morphia  will  have  the  double  effect  of  soothing  the 
pain  and  restlessness,  and  of  lessening  the  depressing  effects  of  loss  of 
blood ;  sinapisms  may  be  applied  to  the  upper  extremities  by  way  of 
diverting  the  circulation  in  that  direction.  In  cases  of  extreme  collapse 
the  hypodermic  injection  of  ether  may  be  employed,  and  a  solution  of 
common  salt  (a  teaspoonful  to  a  pint  of  boiled  water)  may  be  injected 
into  the  veins  or  into  the  rectum,  as  may  be  more  practicable.  Some 
French  authors  have  recommended  that,  in  the  early  stage,  venesection 
should  be  practised  once  or  twice,  to  produce  a  derivative  effect  on  the  pel- 
vic vessels,  and  to  lessen  the  pressure  in  the  systemic  circulation  generally, 
and  on  the  internal  bleeding  points  more  particularly.  Aran  recommended 
twenty  or  thirty  leeches  over  the  abdomen  on  the  .first  day,  fifteen  to 
twenty  on  the  second,  and  twelve  to  fifteen  on  the  third  day,  if  the 
constitutional  condition  of  the  patient  would  bear  it  and  the  feebleness 
were  not  too  great.  He  testified  to  the  favourable  results  of  such  treat- 
ment, and  to  the  shorter  duration  of  the  cases.  He  supported  the 
strength  during  depletion  by  nutritious  diet,  and  followed  up  the 
leeching  by  blisters  and  other  forms  of  counter-irritation  to  the  abdomen. 
Keither  general  nor  local  depletion  has  found  favour  in  Great  Britain. 

The  local  application  which  has  been  found  most  effective  is  an 
ice-bag  over  the  hypogastrium ;  or,  if  ice  cannot  be  procured,  cold  com- 
presses over  the  seat  of  pain.  Hot  fomentations  and  poultices  are  to 
be  sedulously  avoided  lest,  in  the  attempt  to  relieve  pain  by  their  use, 
they  should  promote  the  further  flow  of  blood  internally.  The  diet 
should  be  simple,  unstimulating,  only  enough  to  prevent  exhaustion ;  and 
all  drinks  should  be  cool  or  cold,  so  that  the  circulation  be  not  suddenly 
stirred.  Foi-  the  same  reason  if  brandy  or  other  stimulant  be  given  — 
and  this  ]nay  be  urgently  needed — it  should  l)e  given  only  in  small  quan- 
tities frequently  rei^eated.  Various  astringents  and  hemostatics  may 
be  administered  if  thought  desirable  —  sulphuric  acid,  tannic  or  gallic 
acid,  acetate  of  lead,  perchloride  of  iron,  ergot  (by  hypodermic  injection), 
digitalis,  etc.  Whichsoever  the  agent  chosen  it  may  be  well  to  combine 
it  with  opium.  When  the  symptoms  of  shock  have  subsided,  and  the 
period  of  reaction  sets  in,  it  becomes  necessary  to  prescribe  for  the  febrile 
symptoms,  and  to  combat  the  signs  of  local  pcu'itonitis.    Frequent  vaginal 


PELVIC  HjEMATOCELE  555 

or  even  external  examination  should  be  avoided,  especially  with  the 
sound  or  other  instruments,  as  disturbing  to  the  patient  and  likely  to 
interfere  with  the  integrity  of  the  adhesions  forming  round  the  extra v- 
asated  blood.  For  the  same  reasons  the  use  of  purgatives  should  be 
avoided.  The  urine  should  be  drawn  off  with  a  catheter,  and  every 
movement  or  disturbance  of  the  patient  obviated  as  much  as  may  be. 
The  main  points  to  be  attained  are  absolute  repose  and  the  relief  of  pain 
by  opium  or  morphia,  which  may  be  administered  by  the  mouth,  rectum, 
or  hypodermically  as  seems  most  expedient.  If  thought  desirable  the 
ice-bag  can  be  continued,  as  it  may  relieve  pain  and  lessen  the  intensity 
of  the  peritonitis.  If  the  signs  of  local  peritonitis  are  very  severe,  and 
the  patient's  strength  will  bear  it,  the  application  of  a  few  leeches  to  the 
hypogastrium  or  anus  may  now  be  an  advantage ;  but  they  cannot  be 
applied  to  the  cervix  uteri  without  more  disturbance  than  is  desirable. 
Leeching,  with  hot  vaginal  douches,  as  recommended  by  Bernutz  and 
Goupil,  are  less  objectionable  at  a  later  stage.  These  Bernutz  advises 
at  the  approach  of  a  eatamenial  period  both  to  promote  the  flow,  and  to 
facilitate  the  absorption  of  the  pelvic  tumour. 

In  regard  to  the  siur/ical  treatment  of  the  primary  attack  there  has 
been  great  fluctuation  of  opinion ;  but  the  matter  seems  now  to  be  settled 
absolutely  in  favour  of  non-interference  in  the  extraperitoneal  form,  and 
also  in  a  large  proportion  of  intraperitoneal  cases.  The  exceptions  to 
this  rule,  more  particularly  in  the  last-named  class,  are  those  instances 
where  the  quantity  of  blood  effused,  whether  it  result  from  the  rupture 
of  an  abnormal  pregnancy,  or  from  some  other  cause,  is  obviously  so  large 
or  continuous  that  there  is  little  chance  of  its  becoming  successfully 
encysted ;  and  the  patient  is  evidently  doomed  if  left  to  the  natural 
powers  of  recovery.  In  such  instances,  probably  the  only  chance  of 
saving  the  patient  is  the  performance  of  laparotomy  at  once,  or  as  soon 
as  the  first  rally  from  shock  will  permit,  and  the  securing  of  the  bleed- 
ing points,  with  the  removal  of  the  clots.  Could  we  be  certain  of  the 
diagnosis  in  cases  of  rupture  of  tubular  and  other  forms  of  extra-uterine 
gestation,  there  would  no  doubt  be  a  consensus  of  opinion  as  to  the  pro- 
priety of  opening  the  abdomen  as  soon  as  practicable  after  the  occurrence 
of  the  "  cataclysmic  "  or  "  dramatic  "  symptoms  so  rapidly  supervening. 
For  not  only  is  there  the  risk  of  one  attack  of  haemorrhage  succeeding 
another,  but  tliere  is  the  danger  of  the  ovum  becoming  necrosed  in  the  per- 
itoneal cavity,  and  producing  septic  infection;  or  possibly,  if  the  patient 
recover,  of  the  continued  development  of  the  ovum  either  in  its  original 
abnormal  seat,  or  in  some  other  locality  to  Avhich  it  has  been  transplanted. 
In  these  latter  circumstances  a  primary  operation  Avould  lie  but  to  antici- 
pate what  most  probably  would  be  required  later.  Unfortunately  accurate 
diagnosis  is  frequently  so  little  assured  that  the  question  of  operating 
must  be  determined  rather  by  the  urgency  of  the  symptoms  than  by  the 
pathological  cause.  If  doubt  exists  it  is  Avise  to  abstain  from  surgical 
interference,  for  not  only  have  large  extravasations  of  blood  producing 
voluminous  intra-  and  extraperitoneal  tumours  been  entirely  resolved, 


556  SYSTEJ/   OF  GYNECOLOGY 

but  there  is  reason  to  believe  that  ova  extruded  into  the  peritoneal  cavity 
may  occasionally  be  absorbed,  and  thus  give  no  further  trouble. 

The  rule  of  non-interference  by  primary  surgical  procedure  in  other 
cases  than  those  associated  with  abnormal  pregnancy  has  been  evolved 
from  the  experience  of  many  authorities.  Nelaton  at  first  employed 
the  method  of  puncture  and  evacuation  in  all  cases  indiscriminately.  In 
several  instances  where  puncture  was  practised  the  patients  were  attacked 
with  purident  infection  and  died.  This  led  to  a  modification  of  treat- 
ment, and  artificial  evacuation  was  resorted  to  only  when  the  symptoms 
were  urgent.  Later  Nelaton  taught  that  surgical  interference  was  only 
warrantable  wlien  such  threatening  symptoms  were  present  as  to  cause 
apprehension  of  rupture  of  the  adhesions  forming  the  parietes  of  the  cyst, 
and  extravasation  of  the  contents  into  the  general  peritoneal  cavity. 
Thus  where  a  hsematocele  of  considerable  size  already  existed,  and 
appeared  to  be  increasing  in  size  —  being  attended  by  constant  and 
violent  pain — he  concluded  that  secondary  inflammation  was  going  on 
in  the  cavity,  and  that  the  cyst  walls  would  probably  give  way,  and  fatal 
peritonitis  be  the  result.  The  statistics  of  Voisin,  published  in  his  ex- 
cellent monograph,  although  not  now  recent,  were  decidedly  adverse  to 
artificial  evacuation  as  a  general  plan  of  treatment,  and  led  him  to  prefer 
an  expectant  method,  unless  the  case  were  exceptional  and  threatening. 
Thus  out  of  twenty  cases  where  surgical  interference  was  resorted  to, 
fifteen  recovered  and  five  died.  In  contrast  Avith  this,  out  of  twenty- 
seven  cases  treated  by  the  expectant  method,  twenty-two  recovered  and 
five  died.  Deducting  from  the  last  class  two  deaths  in  which  hsematocele 
was  apparently  not  the  immediate  cause  of  death,  the  mortality,  when 
no  operation  was  performed,  was  one  in  nine,  but  was  one  in  four  when 
an  artificial  opening  was  made.  Voisin's  statistics  were  probably  too 
limited  to  form  a  trustworthy  guide,  and  these  are  sources  of  fallacy 
which  must  be  guarded  against.  Thus  it  does  not  appear  whether  the 
cases  operated  upon  and  chronicled  by  Voisin  were  slight  or  severe. 
He  was  a  pupil  and  follower  of  Nelaton,  and  therefore  it  is  probable 
that  some  of  Voisin's  cases  treated  by  puncture  were  instances  of  the 
worst  form,  and  that  an  opening  was  imperatively  called  for  by  the 
severity  of  the  symptoms.  The  results  tabulated  by  West  show  that 
of  fifty-five  cases  treated  on  the  expectant  plan  forty-three  recovered 
and  twelve  died,  while  of  forty -eight  cases  of  surgical  interference  forty 
recovered  and  eight  died.  Here  again  sources  of  fallacy  may  lower 
the  value  of  tlie  statistics,  unless  it  be  clearly  shown  whether  the  cases 
operated  upon  were  of  such  gravity  tliat  they  could  not  safely  have  been 
left  to  the  expectant  method. 

Meadows  boldly  advocated  a  more  frequent  recourse  to  puncture 
in  cases  where  the  quantity  of  blood  effused  was,  comparatively 
speaking,  inconsiderable  in  amount.  He  made  use  of  Voisin's 
statistics  in  support  of  his  contention.  At  the  time  there  was  no 
great  difficulty  in  showing  that  the  figures  relied  upon  by  Dr. 
Meadows  were  untrustworthy,   because   sources  of   fallacy  were   not 


PELVIC  HEMATOCELE  557 

sufficiently  eliminated ;  and  both  opinion  and  practice  in  later  days 
have  steadily  veered  towards  a  more  conservative  method,  even  in  cases 
deemed  to  be  intraperitoneal.  Following  the  precepts  of  Nelaton,  such 
later  writers  as  Thomas,  Gusserow,  Pozzi,  and  others,  only  recommend 
surgical  interference  in  serious  cases,  each  of  which  is  to  be  judged  by  its 
individual  peculiarities.  Auvard  goes  so  far  as  to  say  that  nineteen  out 
of  twenty  cases  of  hcematocele  will  end  well  by  simply  ensuring  repose  in 
bed.  In  striking  contrast  to  this  is  Lawsou  Tait's  opinion  that  nearly 
all  cases  are  fatal  if  not  operated  upon.  He,  however,  looks  upon 
almost  all  cases  of  intraperitoneal  haemorrhage  as  due  to  tubal  pregnancy, 
and  has  been  in  the  singular  position  of  seeing  none  other. 

ISTo  division  of  opinion  exists  as  to  the  right  course  to  pursue  in  the 
later  stages  of  haematocele.  When  indications  of  suppuration  are  once 
clearly  established,  artificial  evacuation  should  be  undertaken  as  soon 
as  practicable ;  not  only  by  way  of  obviating  the  possible  catastrophe  of 
the  suppurating  cyst  bursting  into  the  peritoneal  cavity,  but  also  Avith 
the  object  of  securing  a  drainage  more  favourable  to  the  recovery  of  the 
patient  than  if  the  abscess  be  left  to  spontaneous  rupture.  It  has  been 
pointed  out  that  spontaneous  evacuation  of  haematocele  is  apt  to  take  place 
through  the  intestine,  because  a  larger  surface  of  the  bowel  is  surrounded 
by  the  tumour  than  of  the  vagina,  uterus,  or  bladder.  This  is  not  nearly 
so  favourable  an  exit  as  by  the  vagina,  where  drainage  may  be  established 
without  setting  up  the  irritation  which  by  the  rectum  is  inevitable. 
Evacuation  should  therefore  always  be  made  by  the  vagina  when  pos- 
sible. There  may  be  a  certain  number  of  cases  where,  notwithstanding  the 
presence  of  general  signs  of  suppuration,  fluctuation  cannot  be  felt  by  the 
vagina.  In  these  instances  exploration  must  be  made  by  the  rectum 
as  well  as  by  the  vagina,  and  the  question  of  opening  be  determined  by 
the  result.  Thanks  to  the  modern  use  of  antiseptics,  both  abdominal 
sections  and  artificial  evacuation  can  now  be  undertaken  with  less  risk  of 
septic  infection  than  in  former  days.  The  admission  of  air  into  the  sac, 
setting  up  putrefaction,  the  recurrence  of  secondary  peritoneal  inflamma- 
tion, and  the  renewal  of  haemorrhage,  were  common  results  in  former 
times  when  incisions  or  puncture  were  practised  either  before  or  after 
suppuration.  The  dangers  of  operation,  nevertheless,  are  multifarious 
and  not  lightly  to  be  encountered.  A  patient  under  the  conjoint  care  of 
Malgaine  and  Nelaton  died  of  haemorrhage  from  a  posterior  uterine  artery 
which  was  wounded  by  puncture ;  and  a  patient  operated  upon  by 
Hugier  died  of  peritonitis  provoked  by  injecting  warm  water  to  wash  out 
the  contents  of  the  cyst.  Eecent  results  happil}'-  testify  that  operations 
on  hematocele,  when  imperatively  called  for  and  carefully  conducted, 
are  somewhat  less  perilous  than  at  one  time  they  appeared  to  be. 
Matthews  Duncan,  a  careful  observer  and  a  decided  conservative  in 
reference  to  operations,  and  Professor  Braun,  both  testify  to  the  truth 
of  this  statement.  P>oth  observed  a  shorter  duration  and  more  rapid 
cure  after  artificial  evacuation  in  appropriate  cases  than  they  expected. 
ImprovcMuont  in  the  result  of  operations  is  partly  to  be  attributed  to  the 


558  SYSTEM   OF  GYNECOLOGY 

better  selection  of  cases,  partly  to  the  nature  of  the  operation,  and 
largely,  to  the  introduction  of  antiseptic  precautions.  In  the  earlier 
oj)erations  puncture  of  the  sac  by  a  trocar  ^vas  chiefly  practised ;  and 
this,  while  it  allowed  the  admission  of  air,  probably  carrying  germs  of 
disease  -with  it,  relieved  the  tension,  but  did  not  ensure  free  drainage 
or  the  exclusion  of  clots.  Sir  James  Simpson  long  ago  recommended, 
instead  of  puncture,  a  freer  opening  with  a  tenotomy  knife,  and  gradual 
enlargement  with  the  fingers,  so  as  to  lessen  the  chance  of  wounding 
large  vessels,  and  to  permit  more  solid  matters  to  be  discharged.  This 
larger  opening  by  the  knife  is  now  generally  admitted  to  be  the  best 
practice  :  in  addition  to  other  advantages  it  permits  the  more  ef&cient 
antiseptic  treatment  of  the  cavity,  which  can  then  be  stuffed  with  iodo- 
form gauze  to  obviate  the  formation  of  septic  products  within.  The 
gauze  must,  of  course,  be  introduced  with  great  gentleness,  and  under  no 
circumstances  should  fluid  be  injected,  lest  the  fragile  adhesions  forming 
the  cyst  boundaries  towards  the  peritoneum  be  broken  down.  An  open- 
ing by  the  vagina  may  not  always  prevent  a  spontaneous  opening  in 
another  direction.  In  a  case  of  Dr.  West's,  puncture  by  the  vagina  was 
followed  by  an  opening  into  the  bowel ;  hence,  if  spontaneous  evacua- 
tion by  the  rectum  seem  inevitable  from  pointing  in  that  direction,  it 
may  be  best  to  open  artificially  there,  notwithstanding  the  disadvantages 
named.  The  question  arises,  nevertheless,  whether,  if  fluctuation  in  any 
degree  can  be  detected  by  the  vagina,  it  may  not  be  well  to  make  an 
incision  there,  even  if  discharge  have  already  appeared  by  the  rectum ; 
as  the  counter  opening  will  prevent  the  retention  of  fsecal  and  other 
contents  in  the  abscess  cavity. 

In  summary,  it  may  be  stated  that  as  a  general  rule  it  is  best  to  treat 
cases  of  haematocele  —  intraperitoneal  as  well  as  extraperitoneal  —  by  a 
palliative  method,  relieving  the  symptoms  by  appropriate  remedies,  and 
taking  such  precautions  as  are  likely  to  ward  off  fresh  complications. 
When  the  blood  extravasation  is  extraperitoneal  no  need  to  deviate  from 
this  plan  is  likely  to  arise,  but  it  should  be  pursued  as  far  as  possible 
irrespective  both  of  the  size  and  position  of  the  haematocele ;  and  in  a  large 
proportion  of  cases,  if  perfect  quiescence  be  enforced,  the  tumour,  even  if 
of  considerable  dimensions,  will  gradually  disappear.  If,  however,  the 
symptoms  are  very  severe,  or  the  tumour  once  formed,  instead  of  sub- 
siding, sliows  a  tendency  to  increase,  with  repeated  recrudescence  of 
urgent  symptoms,  it  becomes  a  question  whether,  notwithstanding  the 
risks,  la})arotoniy  should  be  performed  for  the  double  purpose  of  remov- 
ing the  contents  of  the  tumour  and  securing  the  bleeding  points.  In  the 
cachectic  cases  there  would  be  less  hope  of  doing  good  by  operation  than 
in  others ;  each  case  must  be  judged  on  its  own  merits.  Again,  whenever 
in  the  after  stages  of  the  affection  constant  and  severe  pains,  the  occur- 
rence of  rigors,  and  marked  increase  of  temperature  at  nights,  with  other 
hectic  symptoms,  indicate  that  su])f)urati()n  has  taken  place,  then  artificial 
evacuation,  by  the  vagina  if  practica})lc,  becomes  imperative  as  soon  as 
fluctuation  can  Ijo  detected.     In  some  rare  cases,  where  no  distinct  signs 


PELVIC  I/yEMATOCELE  559 

of  suppuration  have  occurred,  the  urgency  and  persistence  of  certain 
severe  symptoms  may  yet  call  for  operative  interference.  Thus  the 
persistence  of  severe  and  chronic  vomiting,  Avhich  has  been  observed 
associated  with  large  hsematoceles,  and  continued  and  alarming  obstruc- 
tion of  the  bowels,  as  observed  by  Meadows  and  others,  may  call  for 
some  diminution  in  the  amount  of  physical  pressure.  In  such  instances 
Routier,  who  at  one  time  preferred  laparotomy,  has  declared  his  prefer- 
ence for  vaginal  incision  as  less  hazardous  ;  and  his  position  is  supported 
by  Zweifel,  von  Strauch,  and  other  authorities.  Eegnier,  again,  prefers 
abdominal  section,  but  his  preference  should  be  regarded  with  caution, 
as  he  would  extend  abdominal  section  to  cases  treated  by  others  on  the 
expectant  plan.  If  there  be  reason  to  suppose  that  haemorrhage  is  still 
going  on  within,  and  that  the  boundaries  of  the  blood-cyst  are  not 
consolidated,  probably  the  least  hazardous  course  would  be  to  perform 
laparotomy  rather  than  make  an  incision  by  the  vagina.  This  operation 
is  the  more  to  be  preferred  where  there  is  a  suspicion  that  the  case  is 
associated  with  ectopic  gestation.  As  to  the  technique  of  this  operation, 
Pozzi  says  that  "the  sac  should,  if  possible,  be  fixed  to  the  abdominal 
wall  by  '  marsupialisation,'  emptied,  plugged,  and  drained.  But  this 
theoretical  manoeuvre  is  rarely  practicable  on  account  of  the  absence 
of  a  well-formed  and  resistant  cyst  wall ;  the  latter  generally  has  no 
individuality,  and  is  simply  formed  by  adhesion  of  neighbouring  parts. 
The  surgeon  may  then  be  forced  to  content  himself  with  antiseptic 
flushing  of  the  cavity."  It  is  obvious,  however,  that  this  flushing  must 
be  of  the  gentlest  character,  lest  the  temporary  adhesions  be  broken 
down.  In  such  a  case  it  would  be  wise  to  plug  the  orifice  with  iodo- 
form gauze,  and  provide  capillary  drainage. 

The  after  treatment  of  hasmatocele  in  its  more  chronic  forms,  and 
more  especially  in  cases  not  operated  upon,  deserves  careful  attention. 
The  indications  are  to  prevent  as  far  as  possible  the  recurrence  of 
haemorrhage  or  other  active  symptoms,  and  to  promote  the  absorption  of 
the  extravasated  blood  with  the  inflammatory  products  surrounding  it. 
It  is  necessary,  therefore,  at  the  catamenial  periods  to  prescribe  abso- 
lute rest  in  the  recumbent  position  until  recovery  is  completed ;  in  the 
intervals  the  amount  of  exertion  should  be  carefully  regulated.  Violent 
efforts  or  straining  should  be  avoided,  as  well  as  all  excitement  of  the 
sexual  organs.  The  bowels  should  be  made  to  act  easily,  and  the  diet 
should  be  nutritious,  but  not  over-stimulating.  If  there  is  anaemia,  and 
this  associated  with  dribbling  bloody  discharge  from  the  uterus,  acid 
chalybeates,  such  as  the  sulphate  or  perchloride  of  iron,  combined  with 
mineral  acids  and  other  tonics,  may  be  prescribed.  The  iodides  and 
bromides  of  iron  have  been  found  useful  in  promoting  the  absorption  of 
deposit  and  thickening  if  they  continue  long  after  an  attack ;  and  these 
may  be  aided  by  the  local  application  of  blisters,  tincture  of  iodine,  and 
mercurial  and  belladonna  ointments.  Sir  James  Simpson  used  vaginal 
suppositories  or  pessaries  medicated  with  iodides  and  mercurials  for  this 
purpose. 


56o  SYSTEM    OF  GYNECOLOGY 

The  precautions  to  be  adopted  wheu  spontaneous  evacuation  has 
taken  place  will  depend  on  the  locality  of  exit.  If  opening  has  taken 
place  per  vaginam,  then  probably  all  required  will  be  strict  antisepsis  and 
generous  diet.  If  perforation  has  been  through  the  intestine,  in  addition 
to  tonics  and  good  food,  opium  or  morphia  may  be  required  to  stay  the 
diarrhuia,  and  such  precautions  as  are  possible  to  ward  off  the  tendency 
to  recurring  peritonitis  and  septiceemia.  The  question  of  counter-opening 
into  the  vagina  may  arise  in  such  cases,  particularly  where  the  symptoms 
are  grave,  and  there  seems  a  likelihood  of  reaching  the  most  depending 
part  of  the  sac  through  the  genital  canal. 

As  the  patient,  even  when  fairly  recovered,  may  still  have  indications 
of  impaired  health,  deranged  menstruation,  and  possibly  of  deposit 
remaining  in  the  pelvis,  care  and  precaution  will  be  required  for  a  pro- 
longed and  indefinite  period.  The  avoidance  of  great  exertion  or  of  much 
travelling  should  be  enjoined,  and  rest  at  the  monthly  periods.  Change 
of  air  should  be  prescribed  if  it  can  be  procured,  and  every  advantage 
which,  by  improving  the  general  health,  will  conduce  to  full  recovery. 

W.  0.  Peiestley. 


REFERENCES 

1.  Amer.  Syst.  of  Gyn.  Ed.  by  Mann,  1887.— 2.  Asch.  Cent.  f.  Gynec.  1887.  — 3. 
AuvARD.  Traits prat.de gyn.  W^.  —  4.  Baldy.  Text-Book  of  Gyn.  1?>M.  —  5.  Bandl. 
Billroth's  Handhuch,  1879. — 6.  Barlow.  Edin.  Med.  Jour.  1841.  —  7.  Barnes.  St. 
Thomas'  Hosp.  Reports,  1870;  and  Obstet.  Trans,  vol.  xiii.  etc. — 8.  Bernutz.  Archives 
de  ni^decine,  1848;  and  Diseases  of  Women,  by  Bernutz  and  Goupil,  Syden.  Soc.  ed. — 
9.  BiEGEL.  Arch.  f.  Gijn.lSn.  — 10.  Bourdon.  Bevue  medicate,  ISil.  — 11.  Braun. 
IVeiner  Med.  Wochenschr.  1H61.  — 12.  Breslau.  Monat.  f.  Geburt,  etc.  vol.  ix.  — 13. 
Byrne.  On  Pelvic  Hsemnt.  1862;  and  Obstet.  Soc.  New  York,  1888.  — 14.  Crede. 
Monatschriftf.  Geburt  und  Kind.  vol.  ix.  — 15.  Cullingworth.  Obstet.  Trans.  1890. — 
If).  Dolbeau.  Med.  Times  und  Gazette,  \^Ti.  — 17.  Duncan,  Matthews.  Edin.  Med. 
Jour.  18(j2  and  1865.  — 18.  Emmet.  Principles  and  P7'act.  of  Gi/n.  ISSi. — 19.  Engel- 
hard. Archiv.dejnedec.  1857.  —  20.  Fenerly.  The.ieinaug2ir ale,  18!)5.  —  21.  Ferrer. 
Arch.  f.  Heilk.  1862,  No.  5.-22.  Follin.  Gazette  des  hopit.  1855.-23.  Fritsch. 
Volkinunn's  Samrnlung,  No.  56.  —  24.  Gallard.  Union  medicate,  1855;  Gaz.  hebdom. 
1858.  —  25.  Goupil.  Syd.  Soc.  Trans.  —  26.  Guerin.  Clin.  Led.  Dis.  of  Female  Goi. 
Org.  p.  4.y.).— 27.  Gusserow.  A7-ch.fiir  Gyn.  W}6-(i7.— 28.  Hugier.  Lecture  before 
Surg.  Soc,  Paris,  1851.— 29.  Imlach.  Brit.  Med.  Jour.  1885  and  1886.-30.  Lauor- 
DORiE.  Gazette  des  hopit.  185i.  —  31.  Laugier.  Comptesrendus,vo].x]. — 32.  M'Clin- 
TOCK.  Diseases  of  Women,  1865,  etc. — 33.  Madden.  Dub.  Jour.  Med.  Sci.  1892. — 
'.a.  Madge.  Obstet.  Trans.  Y()].m. — 35.  Martin.  Dusextra-periton.peri-xit.hxmatom. 
1H81. — '■')i'>.  Meadow.s.  Obstet.  Trans.  \iA.-x\\\.  —  37.  Monod.  Bull,  de  la  Soc.  de  Chir. 
1851.  —  38.  Nfi;LATON.  Gazette  des  hopit.  185\.  —  39.  Nonat.  Traits  prat,  des  nial.  de 
I'ul^rus,  etc.  1874. —  40.  Olshausen.  Archiv  f.  Gyn.  1870.-41.  Phillips.  Obstet. 
Trans.  1887.-42.  Piogey.  Bull,  de  la  Soc.  Aiiat.  1850.-43.  Playfair,  W.  S.  Obstet. 
Trans.  1884  and  1889. — 44.  Ponckt.  "  Hajinatocele,"  Did.  ewycl.  de  m^d.  sc.  m6d. 
1886;  Jlsjematocele  p(;ri-ut6rine,  Thes.  1877.  —  45.  1'<>Z7A.  TreatL'se  on  Gynxcol.  Syd. 
Soc.  1893. — 46.  Priestley.  Art.  "  Hajmatocele."  Raynohla'  Sy.ftem  of  Med.  187'.). — 
47.  Pukch.  De  V Ildmatoeele  p^ri-ut^rine  et  de  .fes  sources.  Montpolier,  1858. — 48. 
Rkcamier.  Lancette  Frunraise,  July  18.31. — 49.  Regnier.  Bull.  Soc.  de  mdd.  prat. 
1892.  —.50.  RouGET.  Jour,  de  la  Physiol,  de  I'homme,  etc.  1858.-51.  Routier.  Annal. 
de  gyn.  Jany.  1890. — 52.  Scanzoni.  Diseases  of  Women.  American  edit.  —  .53. 
Sch'koedei:.  Ilandbiiclid/'r  Krank.etc.  etc.,  und  Arch.  f.  Gyn.  Bd.  v. —.54.  Skvfert. 
See  TuckweH'H  Essay. — .55.  Simpson,  Sir  J.  Y.  Disea.ies  of  Women. — 5().  Sutton, 
Bland.    Med.-Chir.  Trans.  1890. — .57.    Tait,  Lawson.    Diseases  of  Wonun,  1889.— 


BENIGN  GROWTHS   OF  THE    UTERUS  561 

58.  Tardieu.  ^«?ia^  deAj/jrie/ie,  published  1834. — 59.  Thorntox,  Knowsley.  Obstet. 
Treats.  1889, — GO.  Tilt.  Diseases  of  Women.  —  61.  Tuckwell.  0 u  Effusions  of  Blood 
in  the  Neighbourhood  of  the  Uterus,  1863. — 62.  Veit.  Centralhlatt  fiir  Gyn.  1891. — 63. 
Velpeau.  Recherchessur  les  cavit^s  closes,  IS-il. — 64.  Vigues.  Des  Tumeurs  sanguines 
de  I' excav.  pelv.  1S50. — 65.  Voberk.  Bull,  de  la  Soc.de  Chir.  1851;  and  Gazette  des 
hopit. 'iS55. — 66.  VoisiN.  Be  l' Hematocele  r^tro-ut^rine,  1H58.  —  67.  A^onStrauch.  St. 
Petersburger  Med.  Wochen.  1891.  — 68.  Weber,  F.  Berlin,  klin.  Wochen.  Chir.  No. 
1,1873. — 69.  YTkst.  Diseases  of  Women. — 70.  Williams  (Sir  John).  "  Serous  Peri- 
metritis," Trans.  Obstet.  Soc.  1885.  —  71.  Winckel.  Die  Path,  der  Weibl.  Sex.  Org. 
1881;  and  Lehrbuch  der  Frank,  1892.  —  72.  Zweifel.    Arch.  Gyn.  Bd.  xxii. 

W.  0.  p. 


BENIGN   GEOWTHS   OF  THE   UTEKUS 

The  uterus  is  undoubtedly  tlie  most  common  seat  of  new  growths  in 
the  human  body.  Exact  statistics  as  to  their  relative  frequency  cannot 
be  quoted;  indeed,  precise  statistical  evidence  of  the  relative  frequency  of 
neoplasms  generally  must  be  untrustworthy.  From  the  researches  of 
V.  Gurlt  however,  compiled  from  the  Vienna  Hospital  Reports,  which 
embrace  15,880  cases  of  tumour,  females  exceeded  males  in  the  propor- 
tion of  seven  to  three ;  and  of  this  large  majority  in  the  former,  uterine 
growths  accounted  for  25  per  cent,  while  the  other  sexual  organs,  includ- 
ing the  mamma,  contributed  about  20  per  cent. 

The  cause  of  this  great  frequency  of  new  growths  in  the  uterus  is 
unknown ;  but  when  we  consider  the  variety  of  its  tissues,  its  constantly 
recurring  periodic  engorgements,  and  the  enormous  hypertrophy  it  under- 
goes during  pregnancy,  Ave  may  anticipate  its  special  proneness  to  disease, 
and  in  particular  to  neoplasms. 

That  these  conditions  enter  into  the  causation  of  the  new  growths  is 
proved  by  the  extreme  rarity  of  congenital  growths,  and  by  the  infrequent 
development  of  neoplasms  before  puberty ;  also  after  the  menopause 
simple  tumours  rarely  occur,  and  the  malignant  kinds  in  the  great  majority 
of  instances  are  found  in  women  who  have  previously  borne  children, 
and  may  be  favoured  by  the  bruising  and  laceration  consequent  upon 
parturition. 

Simple  tumours, especially  fibroids,  were  supposed  to  be  more  common 
in  the  coloured  races ;  but  this  assertion  has  lately  been  contradicted. 

Easy  circumstances  seem  especially  to  be  associated  Avith  the  develop- 
ment and  groAvth  of  uterine  fibromyoma,  in  contradistinction  to  the 
preponderance  of  uterine  cancer  in  the  poor  and  badly  nourished. 

The  classification  of  uterine  groAvths  of  a  simple  character  may  be 
most  practically  and  simply  considered  bydividing  them  into  tAvo  primary 
groups  :  (A)  tumours  of  the  muscular  Avail,  and  (B)  tumours  of  the  mucous 
lining. 

A.  Tumours  of  the  Muscular  Wall  are  practically  represented  by 

2o 


562  SYST£Af  OF  GYNECOLOGY 

one  variety,  the  fibromyoma ;  these  tumours,  however,  may  undergo  a 
large  number  of  secondary  changes  that  so  transform  their  original  struct- 
ure, that  one  is  tempted  to  describe  them  severally  as  independent  types 
of  neoplasm.  Some  growths,  such  as  the  cystic,  may  occasionally,  no 
doubt,  develop  as  such;  but  in  the  absence  of  definite  proof  of  this, 
and  on  account  of  their  extreme  rarity,  it  is  more  simple  and  practical 
to  attribute  them  entirely  to  secondary  changes  in  pre-existing  fibroids. 

The  Fibromyomas  —  also  knoAvn  as  fibroid  or  fibrous  tumours,  my omas, 
leiomas,  and  hysteromas  —  are  by  far  the  most  common  of  uterine  new 
growths.  They  are  stated  by  Bayle  to  occur  in  20  per  cent  of  all  women 
over  thirty -five  years  of  age  ;  Avhile  in  women  of  fifty,  Klob  (37)  estimates 
their  occurrence  at  40  per  cent.  Fortunately  these  statistics  were  com- 
piled from  an  exhaustive  and  detailed  examination  of  uteri  after  death, 
in  the  majority  of  which  the  growths  were  so  small  as  to  give  rise  to  no 
inconvenience  or  any  indication  of  their  presence  during  life. 

It  is,  therefore,  of  much  more  practical  interest  to  make  an  approxi- 
mate estimate  of  the  percentage  of  women  who  suffer  from  pelvic 
symptoms  due  to  these  growths.  For  this  purpose  I  have  consulted  the 
case-books  of  the  Edinburgh  Eoyal  Infirmary,  which  show  that  of  2230 
gyneecological  cases,  in  only  176  (8  per  cent)  was  fibromyoma  the  assigned 
cause.  The  figures  thus  obtained  must  necessarily  be  considerably  within 
the  actual  proportion,  as  only  patients  suffering  from  urgent  symptoms 
are  treated  as  in-patients ;  while  a  large  number  of  cases  of  fibroids  are 
attended  with  minor  symptoms.  Further,  as  is  well  known,  these  tumours 
are  more  commonly  met  Avith  in  the  more  affluent  classes  which  do  not 
attend  at  hospitals.  Yet  when  we  compare  the  rarity  of  fibromyoma 
in  g3ai£ecological  practice  with  the  statistics  of  Klob  and  Bayle,  Ibased 
upon  their  presence  in  women  generally,  it  must  be  assumed  that  the 
proportion  of  fibroids,  which  give  rise  to  any  symptoms  whatever,  is 
exceedingly  small. 

Filjromyomatous  tumours  are  associated  with  the  period  of  sexual 
activity.  Their  growth  is  practically  confined  to  the  years  between 
jniberty  and  the  menopause,  and  it  is  doubtful  if  they  ever  originate 
before  or  after  this  period ;  indeed,  if  uncomplicated  by  secondary  changes, 
they  cease  to  grow  after  the  climacteric.  In  Winckel's  tables  two  cases 
are  quoted  as  occurring  in  women  over  seventy  years  of  age ;  and  many 
cases  are  recorded  in  women  over  sixty.  It  is  probable,  however,  that 
these  were  due  to  secondary  changes  occurring  in  pre-existing  and  un- 
noticed tumours,  changes  which  are  by  no  means  an  infrequent  residt  of 
chronic  (jedema  [see  Fibrocystic  Growths,  p.  580].  A  curious  and  inter- 
esting case  is  cited  by  Sutton,  in  which  a  tumour,  supposed  to  be  a  fibroid, 
was  present  for  ten  years  in  the  uterus  of  a  childless  widow,  twice  mar- 
ried, who  had  never  menstruated,  or  shown  any  physiological  evidence 
of  ovulation. 

The  earliest  example  cited  is  in  a  girl  of  ten  years  of  age  (26),  but 
unfortunately  no  account  is  given  of  the  microscopic  structure  of  the 
growth  or  of  menstruation. 


BENIGN  GROWTHS   OF  THE    UTERUS  563 

Opinion  is  divided  as  regards  the  influence  of  the  sexual  functions 
upon  the  development  and  growth  of  fibromyoma ;  but,  strangely  enough, 
this  difference  of  opinion  lies  almost  entirely  between  the  pathologists  on 
the  one  hand,  and  the  gynaecologists  on  the  other.  The  former  maintain 
that  these  growths  largely  predominate  in  the  unmarried,  and  Cohnheim 
(11)  even  asserts  that  sterility  leads  to  their  formation.  Unfortunately, 
however,  no  statistics  have  been  produced  in  support  of  this  assertion. 
The  majority  of  gynaecologists  entertain  an  entirely  opposite  opinion ;  and 
most  trustworthy  investigators  —  such  as  Schroeder,  Winckel,  Gusserow, 
and  others  —  have  adduced  overwhelming  evidence  on  this  side  of  the 
argmnent.  Thus  Schroeder  found  614  married  women  in  792  cases ; 
and  Winckel  and  Gusserow  consider  the  proportion  of  the  married  to 
the  single  to  be  as  two  to  one. 

It  seems  dithcult  at  first  to  reconcile  such  conflicting  statements ;  but 
on  consideration  of  the  very  different  sources  of  information  —  namely, 
post-mortem  examinations  and  clinical  experience  — the  inference  appears 
that  the  great  majority  of  tumours  originate  independently  of  sexual 
irritation,  at  least  so  far  as  intercourse  is  concerned ;  but  that  their  sub- 
sequent groAvth  is  so  favoured  by  its  indulgence  that  symptoms  and 
signs  of  the  presence  of  the  tumour  more  frequently  arise. 

The  influence  of  fibroids  upon  child-bearing  has  at  all  times  been  a 
fruitful  source  of  discussion,  sterility  being  regarded  by  some  observers 
as  an  actual  cause  of  their  development  (Emmet).  Others  look  upon 
sterility  as  a  consequence.  In  support  of  the  latter  opinion  almost  in- 
controvertible evidence  has  been  brought  forward  by  West,  Scanzoni, 
M'Clintock,  Winckel,  Schroeder,  and  many  others,  whose  combined  statis- 
tics show  621  cases  of  absolute  sterility  in  2035  cases  of  fibroids ;  that 
is  to  say,  about  30  per  cent  were  childless.  When  this  is  compared  Avith 
the  average  sterility  in  Avomeu  generally  (10  per  cent)  (17),  one  is  com- 
pelled to  admit  that  they  exercise  a  marked  preventive  influence  on  con- 
ception. That  the  sterility  is  due  to  the  tumours,  and  not  the  tumour 
to  the  sterilit}',  is  strikingly  supported  by  the  important  statistics  of 
relative  sterility  as  quoted  by  Winckel  and  Susserot  (61).  These  afford 
convincing  proof  of  the  undoubted  preventive  effect  of  fibromyomata 
upon  child-bearing.  Their  combined  cases  show  that  99  fruitful  women 
with  fibroids  bore  only  276  children,  an  average  of  2-8 ;  the  normal 
average  of  children  to  each  mother  in  the  same  localit}'  being  \b. 

West  found  that  of  thirty-six  fruitful  women  with  fibroids,  the  average 
number  of  children  to  each  mother  was  scarcely  two;  twenty  of  the 
thirty-six  mothers  had  but  one  child  each,  a  most  striking  contrast  to 
the  statistics  of  Ansell,  which  show  that  normally  only  one  in  thirteen 
mothers  have  but  one  child. 

The  statistics  of  the  effect  of  sexual  excitement  and  child-bearing  on 
the  development  and  growth  of  fibroids  seem  to  lead  to  the  following 
conclusions :  — 

(1)  That  fibromyoma  originates  in  the  majority  of  instances  in- 
dependently of  marriage  and  pregnancy. 


564  SYSTEM   OF  GYNAECOLOGY 

(2)  That  sexual  excitement  in  marriage  favours  their  growth. 

(3)  -  That  they  tend  to  prevent  child-bearing. 

(4)  That-  pregnancy  seems  to  promote  their  growth  to  a  great  extent, 
so  that  future  conception  is  in  many  cases  prevented,  and  signs  and 
symptoms  of  their  presence  are  manifested.  It  will  be  shown,  in  review- 
ing in  detail  the  subject  of  the  effect  of  fibroids  on  pregnancy,  that 
sterility  is  further  promoted  by  the  preventive  effect  of  these  tumours 
on  the  growth  of  the  ovum. 

Pathological  Anatomy. — Eibromyomas  may  be  found  either  in  the 
body  or  in  the  cervix  uteri ;  in  the  former  site,  however,  they  greatly 
predominate,  4  per  cent  only  occur  in  the  cervix.  They  are  said  to  occur 
more  frequently  in  the  posterior  than  in  the  anterior  wall,  although  from 
experience  I  cannot  corroborate  this  statement. 

Their  origin  has  been  and  is  still  a  source  of  much  speculation.  Some 
attribute  them  to  the  organisation  of  blood  accidentally  extravasated. 
Others  state  that  they  have  found  bacterial  colonisation  as  the  nucleus  of 
the  growth,  a  statement  effectually  disproved  by  Marey.  Klebs  attributes 
them  to  a  proliferation  of  the  connective  and  muscular  tissues  of  blood- 
vessels, a  theory  which  is  supported  by  the  general  deposition  of  the 
muscular  bundles  parallel  to  the  vessels  in  the  tumour.  The  actual 
histogenesis  has  yet  to  be  proved. 

In  size  these  growths  vary  from  less  than  a  pea  upwards,  and  have 
been  recorded  as  reaching  the  enormous  weight  of  140  lbs.  (32). 

They  are  most  frequently  multiple,  and  in  but  very  few  instances 
of  apparently  solitary  tumours  will  a  minute  examination  fail  to  detect 
other  small  nodules  in  the  uterine  wall.  In  some  cases  as  many  as  fifty 
independent  tumours  may  be  found  growing  in  the  same  uterus.  A 
marked  excej)tion  to  the  general  rule  of  multiplicity  is  to  be  found  in 
the  case  of  the  so-called  oedematous  fibroid,  Avhich  in  the  large  majority 
of  instances  is  solitary. 

Formed  from  the  same  elements  as  the  uterine  wall,  the  gross 
characters  of  fil^-omyoma  vary  considerably  according  to  the  relative 
excess  of  muscular  or  fibrous  tissue  in  their  structure;  usually  these 
growths  are  of  a  firmer  consistence  than  the  uterine  wall  from  which 
they  spring.  In  some  cases,  when  composed  largely  of  muscular  tissue, 
they  are  soft,  and  give  the  impression  of  a  simple  hyperplasia  of  the 
uterine  tissues.  On  section  the  soft  varieties  have  a  reddish  pink 
api^earance,  and  t(j  the  naked  eye  are  more  imiform  in  structure  than 
the  commoner  liard  variety.  The  latter  on  section  appear  pinky  white, 
with  wavy,  glistening,  whitish  bands  coursing  in  every  direction,  but  with 
a  decided  tendency  to  form  whorls  round  individual  centres,  an  appear- 
ance which  gives  rise  to  the  not  inapt  comparison  to  "  a  ball  of  wool." 
Tliis  characteristic  appearance  is  due  to  the  mode  of  growth  of  the 
tumour,  the  muscular  tissue  closely  following  and  running  ])arallel  to  the 
blood-vessels.  Thus  they  closely  simulate  development  from  a  number  of 
distinct  centres;  but  their  origin  from  a  single  focus  is  proved  by  other 
facts,  such  as  the  extreme  rai-ity  of  iriore  than  on(;  nodule  within  the 


BENIGN  GROWTHS   OF  THE    UTERUS  565 

same  capsule,  and  the  smooth,  spherical  form  of  all  nodules  free  from 
irregular  pressure.  The  cut  surface  of  fresh  sections  is  uneven,  the 
elasticity  of  the  fibrous  tissue  causing  the  softer  muscular  bundles  to 
bulge  externally. 

The  growth  is  usually  enveloped  in  a  false  capsule  derived  from  the 
uterine  tissues,  which  have  undergone  marked  compression  changes  from 
the  ever  increasing  and  constant  circumferential  pressure  caused  by  the 
developing  tumour. 

As  the  capsule  is  formed  by  the  surrounding  tissues,  it  varies  in 
thickness  according  to  the  original  site  of  development  of  the  tumour. 
Thus  when  the  growth  originates  in  the  middle  layer  of  the  uterine  wall, 
the  surrounding  capsule  will  be  thick  and  well  formed ;  but,  if  the 
tumour  develop  in  the  external  or  internal  layers  of  the  uterine  mus- 
cle, the  intervening  muscular  layers  between  it  and  the  superimpose 
peritoneum,  or  mucosa,  must  necessarily  be  but  scanty,  and  the  capsule 
correspondingly  thin ;  indeed,  in  some  cases  the  muscular  capsule  is 
entirely  absent,  the  tumour  being  covered  by  the  peritoneum  or  mucosa 
alone. 

Between  the  tumour  and  the  so-called  capsule  there  is  a  layer  of 
loose  connective  tissue  in  which  the  growth  is  embedded,  that  in  some 
cases  allows  of  its  ready  enucleation.  In  other  instances,  however,  there 
are  many  strong  muscular  and  fibrous  bands  passing  between  the  growth 
proper  and  the  capsular  Avail,  Avhich  prevent  a  ready  enucleation ;  in 
some  of  the  softer  tumours  these  intervening  bands  are  so  numerous  as 
to  obscure  any  line  of  demarcation  betAveen  the  tumour  and  surround- 
ing muscle,  and  the  Avhole  mass  thus  appears  to  be  a  simple  hyperplasia 
of  the  uterine  Avail. 

In  the  capsule,  and  em1)edded  in  the  loose  connective  tissue  betAveen 
it  and  the  tumoiir,  may  be  seen  the  numerous  and  large  blood-vessels 
surrounding  the  tumour,  from  Avhich  it  derives  its  nourishment.  These 
do  not  penetrate  the  substance  of  the  growth  to  any  great  depth,  and 
thus  sections  of  Avell-formed  vessels  are  but  seldom  found  aAvay  from 
the  periphery. 

Their  vascularity  is  but  slight  in  comparison  to  that  of  the  uterine 
Avail  from  Avliich  they  spring,  as  is  well  shoAA-n  in  Fig.  141,  taken  from  a 
preparation  of  an  injected  uterus  Avith  fibroid. 

In  the  harder  varieties  blood-vessels  are  extremely  scanty,  especially 
toAvards  the  centre  of  the  groAA^th ;  but  in  the  softer  groAvths  they  are 
much  more  numerous.  They  are  rarely  Avell  formed,  hoAvever,  and 
appear  rather  to  be  of  the  nature  of  sinuses.  The  blood-supply,  there- 
fore, is  usually  but  scanty,  and  the  circulation  at  the  best  sIoav  and 
difficult. 

Normally  of  a  smooth,  round,  luiiform  shape,  the  spherical  contour 
of  the  original  nodule  may  becouie  much  modified  by  tlie  effects  of 
irregular  pressure,  or  by  the  development  of  secondary  nodules  in  its 
capsule. 

When  examined  microscopically  these  tumours  are  found  to  be  com- 


566 


SYSTEM   OF  GYNECOLOGY 


posed  entirely  of  miisculaT  and  connective  tissue  elements,  "^'hicli  vary 
Avid^ly  in  relative  quantity.  When  young  and  in  rapid  growth  the 
muscular- tissue,  as  a  rule,  largely  preponderates;  but  it  would  appear 
that  in  the  majority  of  cases  the  connective  fibrous  tissue  slowly  increases 
at  the  expense  of  the  muscular,  which  occasionally  it  almost  entirely 
replaces.     It  is  thus  evident  that  no  constant  appearance  can  be  assigned 

to  the  growth,  as  its  structure  varies 
within  broad  limits.  It  is  usual  in  yoimg 
and  rapidly  growing  tumours  to  lind  the 
muscular  elements  preponderating;  but 
although  I  have  examined  a  large  number 
of  tumours,  I  have  never  yet  seen  an 
example  in  which  (as  some  authors  main- 
tain) the  fibrous  tissue  is  so  scant  a  pro- 
portion that  it  may  be  neglected,  and 
the  tumour  reckoned  as  a  pure  mj^oma. 
The  distribution  of  the  tissues  is 
extremely  various ;  in  some  cases  of  soft 
growths  (Fig.  142)  the  connective  tissue 
may  be  seen  in  the  form  of  definite  tra- 
becule passing  from  the  capsule,  and 
splitting  the  muscle  bundles  into  distinct 
groups;  these  trabecule  at  the  same  time 
carry  the  blood-vessels.  More  frequently 
the  connective  tissue  and  muscular  bun- 
dles are  indefinitely  intermixed  with- 
out any  apparent  regularity  in  their 
distribution,  and  according  to  the  pro- 
portion of  each  so  is  the  tumour  soft 
or  hard  (Figs.  142  and  143). 

The  appearances  presented  by  the 
muscle  bundles  on  section  vary  greatly 
as  is  to  be  expected  from  their  irregular 
disposition  throughout  the  growth,  run- 
ning parallel  as  they  do  to  the  blood- 
vessels. When  cut  longitudinally,  their  elongated  shape  and  rod-like 
nuclei  are  at  once  apparent  and  eliaractcristic ;  while  on  direct  trans- 
verse section  they  closely  simulate  groups  of  round  cells.  When 
obliquely  severed  they  may  have  the  appearance  of  the  cells  of  a  sarcoma. 
Between  the  muscle  bundles  may  be  seen  many  spaces  in  the  con- 
nective tissue,  only  here  and  there  lined  by  endothelium,  and  forming 
true  lymph  channels.  Nerves  terminating  in  the  individual  muscle  cells 
have  been  descriljed  by  Hertz. 

So  far  as  histological  examination  shows,  it  would  appear  that  these 
growths  originate  and  develop  by  the  proliferation  of  muscle  fibres 
around  the  capillaries,  the  connective  tissue  at  the  same  time  being 
slightly  increased.     In  this  manner  they  may  continue  to  grow  rapidly 


Fig.  141.  —  Injected  uterus  with  fibroid, 
showin(2r  numerous  larffe  blood  sinuses 
in  uterine  wall.  From  specimen,  Ana- 
tomical Museum,  Edinburgh. 


BENIGN  GROWTHS   OF   THE    UTERUS 


567 


to  a  large  size,  and  are  known  as  soft  tumours.  In  the  majority  of 
instances,  however,  the  fibrous  connective  tissue  would  seem  slowly  but 
surely  to  increase  at  the  expense  of  the  muscular  elements  Avhich  it 
displaces  ;  the  tumour  thus  becomes  harder  and  more  fibrous,  the  blood- 
vessels are  encroached  upon  and  even  obliterated,  while  the  muscular 
cells  themselves  are  only  to  be  recognised  in  groups  here  and  there. 
This  fibrous  tissue  development  tends  to  take  place  more  in  the  older 
and  central  portions  of  the 
growth,  Avhich  are  less  vas- 
cular than  in  the  periphery 
of  the  tumour,  this  latter 
portion  being  more  freely 
nourished  by  the  vessels 
which  everywhere  pass  to  it 
from  the  capsule. 

The  rate  of  growth,  then, 
must  depend  almost  entirely 
on  active  proliferation  of  the 
muscular  elements  at  the 
periphery.  When  the  fibrous 
tissue  predominates  the  in- 
crease is  extremely  slow,  and 
in  many  cases  ceases  alto- 
gether; while  the  rapidly 
growing  tumour  is  largely 
composed  of  muscle,  and  is 
thus  softer  and  more  vascular 
than  the  hard,  slow-growing, 
or  even  stationary  type.  On  purely  pathological  grounds  it  is,  therefore, 
impossible  to  divide  these  tumours  into  fibrous  and  myomatous  varieties, 
as  the  one  may  insensibly  pass  into  the  other.  The  term  fibromyoma 
must  on  these  grounds  be  considered  as  the  only  strict  scientific  designa- 
tion which  embraces  all  varieties. 

From  a  clinical  aspect,  however,  it  is  well  to  recognise  the  two  types 
of  soft  and  hard  tumours,  as  they  vary  greatly  in  their  rate  of  growth, 
prognosis,  diagnosis,  and  treatment. 

I  have  said  that  all  fibromyomas  originate  in  the  muscular  la3'ers  of 
the  uterine  wall ;  yet  the  site  of  their  development  and  the  subsequent 
direction  of  their  growth  are  of  the  utmost  importance.  Their  clinical 
aspects  and  subsequent  course  differ  so  much  with  their  situation,  that 
for  descriptive  purposes  it  is  necessary  to  distinguish  them ;  and  for 
this  purpose  they  are  clinically  classified  as  Submucous,  Subperitoneal, 
and  Interstitial  (Fig.  144). 

Submucous  Tumours.  —  These  are  represented  by  two  varieties  dis- 
tinguished by  the  presence  or  absence  of  a  muscular  capsule.  The 
"free"  or  non-capsulated  variety  is  usually  developed  from  the  in- 
ternal lavers  of  the  uterine  muscle,  and  is  thus  from  its  origin  closely 


Fig.  142. — Microscopic  section  of  soft  fihrom.voma,  show- 
ing large  muscle  areas  surrounded  by  connective  tissue 
trabeculiE  carrying  the  blood-vessels,     x  40. 


568  SYSTEM  OF  GYNECOLOGY 


connected  with  the  superimposed  mucosa,  which  actually  forms  the 
false  capsule  from  which  it  derives  its  nourishment  (Fig.  145,  1  and 
1a).  The  encapsulated  variety,  on  the  other  hand,  is  developed  in  the 
middle  layers  of  the  uterine  muscle,  and  its  false  capsule  is  thus  formed 
bv  muscular  tissue ;  but  at  the  same  time,  as  its  direction  of  growth  is 
towards  the  uterine  cavity,  it  bulges  the  mucosa  in  front  of  it  (Fig.  145, 
2  and  2a),  and  on  a  superlicial  examination  seems  identical  in  appearance 
with  the  "free"  variety  (Fig.  145).  Though  thus  apparently  similar, 
their  subsequent  growth  and  attachment  to  the  uterus  are  of  sufficient 
practical  importance  to  warrant  distinction. 


Fig.  143.  —  Microscopic   section   of  common  flbromyoma,  showing  muscular  and   connective  tissues 

and  blood  sinus,     x  120. 

In  some  cases  a  primary  encapsulated  tumour  may  become  siibse- 
quently  "free"  by  the  attenuation  and  destruction  of  its  muscular 
capsule  by  pressure. 

The  uterus,  being  highly  intolerant  of  foreign  bodies  in  its  wall,  and 
especially  in  its  cavity,  attempts  by  contraction  to  expel  them.  Thus 
both  varieties  of  submucous  tumours  are  prone  to  be  driven  more  and 
inore  into  the  uterine  cavity,  and  to  become  more  or  less  stalked  or 
pedunculated,  so  as  to  form  what  are  known  as  "  submucous  polypi  " 
(Fig.  14G).  .        . 

That  this  process  of  expulsion  must  be  easier  in  the  free  variety  is 
evident,  as  there  is  no  superimposed  uterine  wall  or  capsule  to  prevent 
its  occurrence.  Should  pedunculation  occur,  the  pedicle  or  uterine  attach- 
ment must  vary  considerably  in  the  two  types;  in  the  "free"  variety 
it  will  be  menjly  represented  by  the  attenuated  mucosa,  while  in  the 
encapsulated  typo  the  muscular  capsule  is  continuous  with  the  uterine 


BENIGN   GROWTHS   OF   THE    UTERUS 


569 


muscle.  In  some  instances  the  latter  may  become  so  attenuated  as  to 
offer  but  a  feeble  union  witli  the  uterus  ;  but  in  many  cases  it  remains 
well  marked  and  firm.  It  will  thus  be  seen  that  the  removal  of  the 
former  is  usually  easy ;  of  the  latter  it  may  be  an  affair  of  consider- 
able trouble. 


Fio.  144.- 


-  Section  of  fibroid  uterus,  from  specimen  in  my  museum,  showingr  —  1,  Polypus  ; 
tial  fibroids  ;  3,  subsei-ous  fibroids  ;  4,  cervical  fibroids. 


The  encapsulated  tumours  grow  to  a  much  larger  size  than  the  free ; 
this  is  due  to  the  preservation  of  the  capsular  circulation  from  which 
alone  fibromyomas  are  nourished.  I  have,  however,  met  with  "  free  " 
polypi  as  large  as  a  foetal  head,  the  growth  being  nourished  by  large 
vessels  situated  in  the  highly  vascular  mucosa;  this  indeed  in  these 
cases  may  bo  considered  as  the  capsule. 

In  many  instances  the  muscidar  capsule  resists  the  attempts  of  the 
uterine  contractions  to  expel  the  growth ;  thus  pedunculation  is  pre- 
vented, although  the  tumour  may  bulge  more  or  less  into  the  uterine 


570 


SYSTEM  OF  GYNAECOLOGY 


cavity :  this  form  is  known  as  the  true  sessile  submucous  fibromyoma. 
A  submucous  polypus  can  only  be  considered  as  the  final  stage  of  the 
attempt  of  the  -womb  to  expel  tumours  primarily  interstitial  or  sub- 
mucous. 

Both  sessile  and  pedunculated  varieties  necessarily  cause  enlargement 
of  the  uterine  cavity,  and  greatly  increase  the  vascularity  of  the  organ. 

At  the  same  time,  by  stimulating 
the  uterine  contractions  for  their 
expulsion,  they  lead  to  much  gen- 
eral increase  in  the  thickness  of  the 
uterine  Avail ;  so  marked,  indeed,  is 
this  hypertrophy  in  some  cases, 
that  it  may  closely  simulate  the 
pregnant  organ  in  the  earlier  months 
of  gestation,  a  similarity  which  has 
given  rise  to  the  descriptive  term, 
"grossesse  fibreuse,"  used  by  Guyon. 
Primarily  the  entire  mucous 
membrane  may  become  congested, 
but  especially  that  portion  which 
actually  covers  the  tumour.  This 
is  well  shown  in  the  injected  uterus 
Avith  contained  polypus  in  the 
Anatomical  Museum  of  Edinburgh 
University  (see  Fig.  146).  From 
this  site  it  is  probable  that  the 
copious  litem orrhages  proceed  which 
are  associated  Avith  this  variety 
of  tumour. 

It  is  averred  by  Wyder  that 
there  is  constantly  an  inflammatory  connective  tissue  thickening  of  the 
entire  mucosa  :  this  process  in  many  cases  which  I  have  carefully  ex- 
amined I  failed  to  detect,  although  in  others  it  Avas  Avell  marked.  l\\ 
certain  cases  a  glandular  endometritis  is  associated  Avith  fibromyoma, 
Avhich  accounts  for  the  severe  accompanying  leucorrhoea  frequently 
complained  of. 

Atrophy,  and  even  ulceration  of  the  superimposed  mucosa,  are  occa- 
sionally met  Avith  as  the  result  of  pressure  from  extrusion  of  the  tumour ; 
and  sh(juld  the  growth,  as  in  the  <'free"  variety  of  i)()lypus,  derive  its 
nourishment  from  the  vessels  of  the  mucosa,  grave  se(!ondary  changes, 
such  as  sloughing  and  gangrene,  are  likely  to  result.  From  the  com- 
pression exercised  by  the  contraction  of  the  uterus,  the  circulation 
through  a  polypus  is  frequently  so  far  arrested  that  it  becomes  more  or 
less  infiltrated  Avith  serum.  This,  if  acute,  may  result  in  death,  slough- 
ing, or  gangrene ;  but  if  slow  it  does  not  entirely  stop  the  nutrition  of 
the  polypus  growth,  though  it  imparts  to  it  a  soft  elastic  consistence 
Avhich  may  lead  to  its  being  mistaken  for  a  cyst  (chronic  oedema). 


Fig.  145. — Diagram  of  growth  of  uterine  fibroids. 
1,  1a,  Free  submucous;  2,  2a,  encapsulated 
submucous;  3,  encapsulated  subserous;  4, 
free  subserous. 


BENIGN  GROWTHS    OF   THE    UTERUS 


571 


Occasionally  actual  cystic  change  is  met  with  in  these  tumours  (see 
p.  58G).  As  the  result  of  uterine  contractions  and  of  gravitation,  all 
uterine  polypi  tend  to  descend  towards  the  vagina,  and  their  pedicles 
become  more  and  more  elongated  and  attenuated  (Fig.  147).  This  may 
go  so  far  that  they  may  project  from  the  vulva,  though  still  attached  to 
the  uterus  (Cullingworth). 

Expulsion  into  the  vagina  may  be  extremely  sudden,  but  usually  it 
is  slow.  In  the  case  of  the  so-called  "intermittent  polypus"  the  os 
uteri  becomes  dilated  at  intervals,  and  the  growth  may  then  be  felt 
projecting  through  it.  This  periodic  dilatation  is  nearly  always  met 
with  during  a  menstrual  period. 


Fig.  146.  —  Encapsulated  submucous  fibroid  becomirii^  polypoidal.     From  specimen  of  injected  uterus 
and  fibroid,  Anatomical  Museum,  Edinburgh.     Ilalf-size.     1,  Uterine  wall ;  2,  capsule  ;  3,  tumour. 

Complete  separation  and  expulsion,  though  by  no  means  unknown, 
are  rarer  events  than  might  be  supposed. 

Partial  inversion  of  the  uterus  not  infrequently  results  from  the  too 
rapid  expulsion  of  these  growths ;  and  several  cases  of  total  inversion 
have  been  recorded. 

From  pressure  on  the  surrounding  uterine  and  vaginal  mucosa,  ulcera- 
tion and  subsequent  adhesions  may  form  ;  and  through  these  secondary 
attachments  the  nutrition  of  the  tumour  may  be  maintained,  even  after 
total  separation  from  its  original  site. 

During  expulsion  the  polypus  may  be  so  firmly  gripped  by  the 
cervix,  that  a  slough  of  the  entire  intravagiual  portion  results.  The 
gangrenous  process  maj',  in  these  cases,  spread  upwards  through  the 
entire  tumour,  when  it  frequently  terminates  fatally. 

Not  only,  as  I  have  said,  may  the  uniform  spherical  shape,  and 


572 


SVSTEJ/  OF  GYNECOLOGY 


smooth  surface  of  a  polypus,  become  mucli  altered  in  contour  from 
surrounding  pressure  and  cervical  constriction,  but  ulceration,  and 
consequent  sloughing  of  the  capsule  may  simulate  closely  a  cancerous 
mass,  and  may  be  mistaken  for  it. 

Si/mptoms.  —  The  characteristic  symptom  of  the  submucous  fibroid  is 
uterine  haemorrhage.  This  occurs  at  a  very  early  stage  in  almost  every 
case,  and  thus  this  variety  of  tumour  comes  much  more  frequently  under 
the  notice  of  the  practitioner  at  an  early  period  than  the  subserous  and 
interstitial  varieties,  which  rarely  give  any  indication  of  their  presence 
till  they  have  attained  considerable  dimensions. 

The  hemorrhage  may  vary  greatly  in  degree ;  but  the  blood  loss,  as 
a  rule,  closely  corresponds  with  one  of  two  factors,  namely,  the  size  of 
___    ^  the  growth  or  the  extent  of  its  pedun- 

culation.  Thus,  if  a  small  growth  the 
size  of  a  walnut  become  polypoidal,  it 
may  give  rise  to  bleeding  as  severe  as 
that  from  a  large  sessile  tumour. 

In  a  typical  case  of  submucous  fibroid 
the  clinical  picture  is  suggestive  and 
characteristic ;  and  shows  a  history  of 
slowly  increasing  menorrhagia,  with 
consequent  anaemia  and  debility.  The 
former,  at  first  but  slight  and  tempo- 
rarily confined  to  the  menstrual  and 
immediate  post-menstrual  period,  be- 
comes more  severe  and  continuous ; 
intermenstrual  bleeding  follows  in  due 
course,  and  the  haemorrhage  eventually 
becomes  almost  constant,  and  the  pa- 
tient is  reduced  to  the  utmost  extremity. 
Variations  from  this  extreme  though 
by  no  means  infrequent  course  of  events 
are  often  met  with.  The  slowly  increasing  menorrhagia  may  rapidly  or 
suddenly  give  jjlace  to  copious  metrorrhagia ;  and  the  character  of  the 
haemorrhage  may  vary  from  a  prolonged  and  constant  oozing  to  sudden 
gushes  of  alarming  magnitude.  Floodings  and  copious  intermenstrual 
Ijleedings  are  very  commonly  associated  with  polypi,  and  are  probably 
due  to  lacerations  of  the  veins  in  the  pedicle.  In  some  instances  these 
must  be  looked  upon  as  the  only  source  of  excessive  bleeding,  as  the 
menstrual  periods  are  frequently  regular  and  quite  normal  in  amount, 
except  when  broken  occasionally,  after  many  mouths  interval,  by  a 
sudden  and  profuse  haemorrhage.  In  some  cases  there  may  be  amenor- 
rhoea  for  months'  duration,  following  a  severe  bleeding  from  an  intra- 
uterine polypus. 

The  source  of  the  bleeding  is  twofold  —  fi'om  the  mucosa  immediately 
covering  the  tumour,  and  from  the  general  lining  of  the  uterus.  Probably 
on  most  occasions  they  are  simultaneous,  but  it  is  certain  that  either  may 


F;g.  147.  — Submucous  polypus.  From  spoei- 
int'ii,  College  of  Surgeons'  Museum, 
Edinburgh.     Half-size. 


act  separately. 


BENIGN  GROWTHS   OF   THE    UTERUS  573 

The  most  active  primary  site  of  the  haemorrhage  is  undoubtedly  the 
mucosa  covering  the  growth;  it  is  always  extremely  vascular,  but  is 
especially  so  in  the  "  free  "  variety,  as  it  contains  the  venous  sinuses 
from  which  the  growth  is  nourished.  In  some  cases,  where  from  pressure 
the  mucosa  becomes  atrophied,  and  its  vascularity  completely  destroyed, 
the  menorrhagia  may  cease.  Should  bleeding  here  continue,  as  it  most 
frequently  does,  the  source  of  the  haemorrhage  will  now  be  found  in  the 
general  mucous  lining  of  the  uterine  cavity,  which  is  usually  thickened 
and  congested,  as  the  result  of  irritation  and  increased  uterine  contraction. 

That  complete  atrophy  and  absence  of  vascularity  of  the  sui^erim- 
posed  mucosa  occurs,  may  frequently  be  observed  in  ulceration  of  the 
lower  pole  of  a  polypus  without  associated  haemorrhage. 

The  metrorrhagia  is  in  many  cases  due  to  the  rupture  of  veins  in  the 
superimposed  vascular  mucosa,  a  condition  which  accounts  for  the  sud- 
denness and  occasional  enormous  amount  of  the  blood  loss.  Indeed, 
fatal  bleedings  from  this  source  have  been  noted  by  Cruveilhier  and 
Matthews  Duncan  (18). 

As  I  have  already  shown,  rupture  of  the  venous  sinuses  in  the 
pedicle  of  a  polypus  may  account  for  those  irregular  and  profuse 
haemorrhages  which  may  be  the  only  indication  of  its  presence.  This 
is  due  to  actual  tearing,  as  the  expulsive  action  of  the  uterus  drives  the 
tumour  outwards. 

The  increased  haemorrhage  at  the  menstrual  epochs,  which  is  asso- 
ciated with  fibromyoma,  frequently  remains  moderate  in  degree  through- 
out the  entire  menstrual  life  of  the  patient ;  there  being  no  tendency  to 
aggravation  or  to  metrorrhagia.  This  obtains  only  in  tumours  which 
remain  small  and  inactive. 

Associated  with  the  s3anptoms  of  haemorrhage  there  is,  in  a  small 
proportion  of  cases,  a  constant  and  abundant  watery  leucorrhoja,  directly 
due  to  concurrent  glandular  endometritis.  When  present  it  effectually 
jirevents  the  restoration  of  strength  so  necessary  after  a  prolonged  or 
profuse  period. 

Pain  in  this  variety,  as  indeed  in  all  varieties  of  fibromyoma,  is  a 
most  variable  symptom.  When  of  considerable  size  the  tumour  usually 
produces  a  sense  of  weight  and  bearing  down  in  the  pelvis ;  and  fre- 
quently, from  the  pressure  of  the  enlarged  uterus  on  adjacent  structures, 
symptoms  similar  to  those  described  under  the  subserous  variety  are 
experienced.  Eetention  of  urine  is  stated  by  Hardie  to  have  been  caused 
by  the  pressure  of  a  small  tumour  on  the  neck  of  the  bladder  through 
the  anterior  uterine  wall. 

Occasionally  intense  and  continuous  pain  is  present  with  small 
tumours,  while  with  others,  which  may  distend  the  uterus  to  the  size 
of  a  six  months'  pregnancy,  little  or  no  discomfort  is  felt. 

Dysmenorrhcwa  is  of  fairly  frequent  occurrence  ;  and  is  due  either  to 
obstructionof  the  flowof  blood  from  the  uterusbv  the  tumour  (mechanical), 
or  to  the  uterine  contractions  which  occur  during  menstruation,  and  which, 
under  the  influence  of  the  tumour  in  its  wall,  are  irregular  and  ]iainful. 


574  SYSTEM   OF  GYN.-ECOLOGY 

Pains  of  a  labour-like  nature  are  constantly  associated  with  polypi,  and 
are  due  to  uterine  contractions  attempting  to  expel  the  growth.  Rellex 
pains  and  neuroses  of  all  varieties,  and  in  every  situation,  may  be  present. 

Sterility  is  common  in  this  variety ;  indeed,  conception  seldom  oc- 
curs. Should  it  do  so,  however,  the  continuance  of  gestation  is  usually 
interfered  with  (see  p.  593). 

The  menopause  is  in  the  majority  of  cases  much  delayed. 

Diagnosis. — The  detection  of  submucous  fibroids  depends  almost 
entirely  on  the  history  of  uterine  haemorrhage,  associated  with  physical 
signs  of  enlargement  of  the  uterus  and  its  cavity.  The  increase  of  the 
uterus  as  a  whole  is  only  to  be  made  out  by  careful  bimanual  examina- 
tion, when  it  will  be  found  symmetrically  enlarged  to  a  greater  or  less 
extent,  according  to  the  dimensions  of  the  neoplasm  within.  It  may 
closely  simulate  pregnancy,  but  the  harder  consistence  and  the  history 
of  haemorrhage  are  usually  sufficient  to  distinguish  it.  Enlargement  of 
the  uterine  cavity  is  to  be  diagnosed  with  the  uterine  sound,  which, 
however,  on  account  of  the  distortion  of  the  canal  by  the  tumour,  in 
some  cases  can  only  be  passed  with  difficulty.  Undue  force  in  the  at- 
tempt must  be  carefully  avoided,  as  laceration  of  the  capsule  may  bring 
about  serious  consequences.  Therefore,  if  much  resistance  be  met  Avith, 
a  flexible  gum  elastic  or  whalebone  bougie  should  be  substituted,  and 
will  generally  be  found  very  serviceable. 

The  conditions  most  apt  to  be  mistakeii  for  fibroid  tumour  ai"e  sub- 
involution, or  chronic  metritis  with  endometritis ;  but  in  these  cases  direct 
derivation  from  a  previous  pregnancy,  and  associated  chronic  cervicitis, 
aid  us  in  the  diagnosis.  Should  the  distinction  be  doubtful,  nothing 
remains  but  direct  digital  examination  of  the  uterine  cavity,  when  the 
absence  or  presence  of  the  tumour  will  ])e  ascertained.  The  intra-uterine 
examination  may,  in  many  cases,  be  performed  easily  during  menstruation, 
when  the  softened  and  gaping  cervix  offers  but  little  resistance  to  the 
introduction  of  the  finger ;  otherwise  artificial  dilatation  must  be  used. 

Polypoidal  tumours,  when  completely  intra-iiterine,  are  to  be 
diagnosed  in  a  similar  manner :  but  being  usually  associated  with 
paroxysms  of  "labour-like"  pains  and  meti'orrhagia,  a  further  valuable 
hint  in  their  diagnosis  is  afforded.  Occasionally  the  intravaginal  cervix 
will  be  found  much  shortened;  in  these  cases  examination  during  a 
menstrual  period  will  seldom  fail  to  reveal  a  presenting  tumour,  the 
so-called  "intermittent  polypus." 

Submucous  polypi  of  the  body  of  the  uterus,  when  intravaginal,  are 
usually  ea^y  of  diagnosis  by  local  digital  examination,  as  the  pedicle  is 
felt  to  pass  upwards  tlirough  the  cervical  canal,  thus  distinguishing 
them  from  cervical  growths.  From  their  large  size,  however,  and  also 
from  adhesions  to  the  vaginal  and  cervical  walls,  a  decision  is  sometimes 
impossible. 

As  the  result  of  tight  constriction  by  the  cervix,  or  ulceration  of  their 
capsule,  polypi  may  become  gangrenous,  and  emit  a  most  offensive  dis- 
charge ;  while  the  tissue  of  the  tumour  itself  becomes  broken  down  and 


BENIGN  GROWTHS   OF  THE    UTERUS 


575 


necrosed.  In  this  condition  they  are  not  infrequently  mistaken  for 
epithelioma;  usually,  however,  the  finger  can  be  passed  beyond  th«^ 
rough  irregular  mass,  when  the  upper  surface  will  be  found  smooth,  a 
condition  which  never  exists  in  malignant  disease.  Further,  digital 
examination  is  seldom  followed  by  the  characteristic  haemorrhage  of 
malignant  growth. 

The  diagnosis  of  polypi  from  inversion  of  the  uterus  can  readily  be 
made  by  the  introduction  of  the  sound  into  the  uterine  cavity.  In 
the  former  case  it  will  pass  farther  than  the  normal  2\  inches ;  if  the 
uterus  be  inverted  the  normal  length  of  the  uterine  cavity  must  be 
diminished.  Careful  bimanual  examination  will  also  demonstrate  inver- 
sion, by  the  absence  of  the  uterine  body  and  fundus,  or  the  cup-shaped 
uterine  depression. 

Simple  as  these  distinctions  may  appear,  errors  of  diagnosis,  leading 
to  grave  mishaps  in  operation,  have  been  made  by  eminent  surgeons. 


Fig.  148.  —  Uterus,  showing  subperitoneal  fibroids.     From  specimen  ;  half-size. 


Subperitoneal  or  Subserous  Fibromyoma.  —  In  these  we  have  a  similar 
origin  and  mode  of  growth  to  the  submucous,  with  the  sole  distinction 
that  the  primary  fibroid  nodule  either  originates  in  the  external  layers 
of  the  uterine  muscle,  and  grows  outwards  under  the  peritoneum ;  or  is 
developed  in  the  middle  layers,  and  grows,  or  is  driven,  in  the  same 
outward  direction. 

That  there  are  "free"  and  encapsulated  varieties,  as  in  the  suIk 
mucous,  is  true ;  but  the  former  rarely  grow  to  dimensions  sufficient  to 
cause  symptoms.  When  primarily  free  they  seldom  grow  larger  than 
a  small  Tangerine  ornngo,  but  from  attenuation  of  the  capsule  large 
primarily  encapsulated  growths  may  be  found  apparently  ''  free." 

It  is  probable  that  the  slowness  of  growth  in  the  "  free  "  subperitoneal 
variety,  as  compared  with  the  submucous,  is  due  to  want  of  nutrition ;  as 
the  vascularity  of  the  peritoneal  covering  of  the  former  is  but  slight 
as  compared  with  the  highly  vascular  mucosa. 


576  SYSTEM  OF  GYNECOLOGY 

The  encapsulated  variety,  on  the  other  hand,  grow  to  enormous 
dimensions,  there  being  no  resistance  to  their  growth  comparable  to 
ihat  met  with  by  the  submucous,  which  has  not  only  to  distend  the 
uterine  cavity,  but  also  to  withstand  the  compressing  force  of  uterine 
contraction. 

Their  attachment  to  the  uterus  naturally  varies  within  wide  limits ; 
but  usually  in  tumours  of  large  size  it  is  of  considerable  thickness : 
although  cases  are  not  uncommon  where  large  growths  have  pedicles  no 
thicker  than  a  goose-quill.  In  certain  instances  the  pedicle  is  so  attenu- 
ated that  without  any  apparent  cause  the  tumour  may  become  actually 
separated  from  the  uterus. 

When  the  pedicle  is  long  and  thin,  such  a  degree  of  mobility  indepen- 
dent of  the  uterus  may  be  obtained,  that  in  their  signs  these  tumours  may 
closely  simulate  ovarian  tumours ;  frequently,  indeed,  they  are  so  regarded 
till  laparotomy  makes  clear  the  diagnosis.  This  difficulty  in  diagnosis  is 
still  further  increased  when  secondary  cystic  degeneration  is  present,  a 
variety  of  change  frequently  met  with  in  stalked  subperitoneal  tumours. 

The  direction  of  growth  of  large  subserous  tumours  is  fortunately 
most  frequently  upwards  into  the  abdominal  cavity,  although  in  some 
instances  they  remain  pelvic ;  this  may  be  due  either  to  accidental  incar- 
ceration or  to  burrowing  among  the  tissues  of  the  pelvis,  with  consequent 
splitting  of  the  layers  of  the  broad  ligaments.  This  latter  most  serious 
condition  is  generally  met  with  in  tumours  which  spring  from  the  lower 
part  of  the  uterine  body  or  supravaginal  cervix. 

Subperitoneal  fibroids  are  usually  associated  with  more  or  less  en- 
largement of  the  uterus,  though  the  degree  of  it  necessarily  depends  on 
the  extent  of  the  attachment  of  the  growth.  I  have,  however,  seen  a 
tumour  weighing  over  7  lbs.  attached  by  a  narrow  pedicle  to  a  uterus 
more  atrophied  than  enlarged.  Thorburn  describes  a  similar  case. 
He  removed  a  tumour  of  12  lbs.  from  a  small  atrophied  uterus. 

In  a  similar  manner  the  cavity  of  the  uterus  is  more  or  less  enlarged 
according  to  the  degree  of  attachment  of  the  growth.  With  a  narrow 
pedicle  this  may  be  but  fractional,  and  after  the  menopause  the  cavity 
may  be  found  actually  shortened  though  a  large  tumour  be  present. 

Large  tumours  attached  to  the  fundus  may,  by  traction  from  upward 
growth,  enormously  increase  the  length  of  the  cavity,  and  at  the  same 
time  attenuate  the  uterus  as  a  whole.  Such  a  case  has  been  described 
V)y  Tiiins,  where  the  uterus  was  so  pulled  out,  that  it  was  repre- 
sented by  a  more  muscular  cord,  the  canal  being  completely  obliterated 
for  a  distance  of  two  inches.  Virchow  avers  that  traction  may  be  so 
extreme  that  complete  separation  of  the  body  from  the  cervix  may 
occur. 

From  localised  peritonitis  and  subsequent  adhesions,  secondary  attach- 
ments may  arise ;  these  have  been  known  to  be  the  sole  means  of 
nourishm(!nt  of  large  tumours  which,  through  laceration  of  the  pedicle, 
have  Ijccoine  separated  from  their  origina.l  site  of  development. 

Tlie  posiliou  of  the  uterus  is  inuc.li  uiodiiiod  by  subserous  growths; 


BENIGN  GROWTHS    OF   THE    UTERUS  577 

as  I  have  said  above,  it  may  be  drawn  up ;  in  other  cases,  however,  the 
increased  weight  may  cause  actual  prolapse.  Other  displacements 
naturally  occur  according  to  the  position  of  the  growth.  If  the  tumour 
be  large  and  pelvic,  and  lie  posteriorly,  the  uterus  may  be  tilted  ui>- 
wards  above  the  symphysis  pubis  as  in  haematocele ;  while  if  small  and 
growing  from  the  fundus,  retroflexion  is  a  common  consequence.  In  a 
similar  manner  when  laterally  placed,  the  uterus  may  be  pushed  to  one 
or  other  side. 

Symptoms.  —  This  variety  of  fibromyoma,  unlike  the  submucous,  has 
no  individual  and  characteristic  symptom,  and  in  many  instances  grows 
to  considerable  dimensions  without  causing  the  slightest  inconvenience. 
Frequently  even  large  tumours  of  this  description  are  casually  found  on 
examination  of  the  abdomen  for  symptoms  in  no  way  referable  to  the  pelvis. 

Should  symptoms  due  to  their  presence  be  complained  of,  these  in 
the  majority  of  cases  are  the  result  of  mechanical  effects  upon  the  uterus 
or  ad j  acent  structures.  Thus  when  small  they  may  cause  displacements  of 
the  uterus,  with  their  associated  discomforts  —  many  flexions  and  versions 
of  the  organ  are  due  to  this  cause.  When  larger  they  give  rise  to  press- 
ure symptoms  which  naturally  vary  according  to  their  size  and  position. 

By  far  the  most  frequent  and  important  symptoms  are  the  effects  of 
pressure  on  the  urinary  system,  which  may  be  affected  in  many  ways. 
Thus  derangements  in  micturition  are  extremely  common,  and  vary 
with  the  site  and  size  of  the  tumour.  If  seated  on  the  anterior  wall  of 
the  uterine  body  they  tend  to  prevent  eas}''  distension  of  the  bladder, 
and  from  their  actual  weight  cause  frequent  micturition.  AVhen  situated 
low  on  the  anterior  wall  they  early  give  rise  to  extremely  painful  and 
distressing  bladder  troubles,  such  as  difliculty  in  urination,  and  even  to 
complete  retention. 

When  large,  and  incarcerated  in  the  true  pelvis,  they  not  only  tend  to 
give  rise  to  severe  bladder  discomforts  such  as  urinary  retention,  dysuria, 
and  cystitis,  but  from  actual  pressure  on  the  ureters  the}^  may  cause 
renal  complications  of  the  most  dangerous  character.  Cases  have 
been  recorded  where  suppurative  pyelitis  and  albuminuria  have  been 
cured  after  the  removal  of  fibroids  (Cabot ;  Porak ;  Skene) ;  and 
doubtless  many  cases  of  overlooked  kidney  complications  may  account 
for  fatal  results  after  operation,  as  shown  by  Pozzi.  In  all  cases  of 
large  fibroids  special  examination  should  be  made  of  the  urine. 

Pressure  on  the  rectum,  though  more  uncommon,  may  cause  obstinate 
constipation  and  severe  tenesmus.  Interference  with  the  pelvic  circula- 
tion, from  pressure  on  the  veins,  may  be  associated  with  haemorrhoids, 
varicose  veins  of  the  vulva,  and  occasionally,  if  exaggerated,  with  oedema 
of  the  lower  extremities. 

From  the  increased  vascularity  of  the  pelvis  due  to  the  presence  of 
the  tumour  and  the  associated  impairment  of  venous  return  by  increased 
intra-abdominal  pressure,  a  bluish  discoloration  of  the  vulva  may  fre- 
quently be  noted,  analogous  to  Jacquemier's  sign  of  pregnancy. 

Pressure  on  the  sacral  nerves  is  frequently  associated  with  agonising 

2p 


578  SYSTEM  OF  GYNAECOLOGY 

pains  iu  the  back  and  legs ;  while  irritation  of  the  sympathetic  ganglia 
may  cause  vomiting  and  other  reflex  neuroses  of  indefinite  characters. 
It  will  thus  be  evident  how  terrible  may  be  the  sufferings  from  a  large 
intrapelvic  fibroid. 

Compression  and  irritation  of  the  peritoneum  may  cause  localised 
peritonitis,  with  subsequent  adhesions ;  in  some  rare  cases  ascites  has 
been  noted.  Actual  sloughing  and  gangrene  of  the  pelvic  soft  parts  may 
occur  from  incarcerated  tumours.  Fortunately,  however,  the  tendency  of 
subperitoneal  tumours  is  to  grow  upwards  into  the  abdominal  cavity  ;  yet 
here,  according  to  their  size  and  position,  they  may  give  rise  to  pressure 
symptoms  of  more  or  less  severity.  Usually  these  are  extremely  slight, 
unless  the  tumour  be  of  enormous  dimensions.  AV^hen  freely  movable 
severe  sickness  and  other  reflex  phenomena  may  be  complained  of.  From 
the  increased  intra-abdominal  pressure  causing  difficulty  in  the  abdominal 
circulation  generally,  and  also  from  the  increased  blood-supply  necessary 
for  the  large  tumour  itself,  a  severe  strain  is  thrown  on  the  heart,  which 
is  therefore  hypertrophied  as  in  pregnancy.  Uterine  haemorrhage,  the 
outstanding  feature  of  the  submucous  variety,  is  but  seldom  present  with 
subserous  growths  ;  but  in  some  cases  from  associated  pelvic  congestion, 
metritis  and  endometritis,  or  the  presence  of  other  small  fibroid  nodules 
dwarfed  by  the  large  growth,  bleeding  may  form  a  marked  symptom. 

The  diagnosis  of  subperitoneal  fibroids  is  at  times  extremely  simple ; 
on  the  other  hand  it  may  be  surrounded  with  difficulties  which  make 
absolute  certainty  impossible.  This  is  in  great  part  accounted  for  by  the 
absence  of  any  specific  symptom  or  sign,  such  as  the  haemorrhage  and  the 
uterine  enlargement  which  we  find  in  the  submucous  varieties.  As  we 
have  already  seen  the  uterus  may  or  may  not  be  enlarged ;  in  like  man- 
ner haemorrhage,  both  menorrhagic  and  metrorrhagic,  are  as  frequently 
absent  as  present :  indeed,  the  symptoms  of  a  given  case  may  simulate 
those  of  other  pathological  conditions,  which  indeed  often  present  physical 
signs  almost  identical.  In  some  cases  it  is  only  by  careful  bimanual  pal- 
pation that  the  presence  of  any  growth  can  be  recognised ;  and  in  many 
a  differential  diagnosis,  even  in  the  hands  of  most  competent  observers, 
can  only  be  provisional. 

For  the  sake  of  simplifying  the  diagnosis  it  may  be  well  to  classify 
these  growths  as  of  three  types :  — 

1,  Those  of  the  fundus  and  anterior  and  posterior  walls  of  the  body 
of  the  uterus,  which  tend  to  become  pedunculated  and  grow  upwards  into 
the  abdominal  cavity.  2.  Those  of  the  side  walls  of  the  uterus  which 
split  the  layers  of  the  broad  ligament.  3.  Those  of  the  lower  part  of  the 
uterus  which  grow  downwards  into  the  pelvis  —  incarcerated  tumours. 

The  diagnosis  of  large  tumours  of  the  first  group  is  usually  easy 
when  the  attachment  to  the  uterus  is  well  marked ;  for  by  the  bimanual 
examination  their  origin  from  the  uterus  can  be  distinctly  felt,  and  the 
two  structures  will  l)e  found  to  move  simultaneously.  Wlieu  the  pedicle 
of  attacliment  is  long  and  tliin  tlie  diagnosis  is  Juucli  more  difficult,  as  the 
uterus  may  be  moved  independently  of  the  growth.    When  small  it  may 


BENIGN  GROWTHS   OF   THE   UTERUS  579 


sometimes  be  difficult  to  decide,  by  simple  palpation,  from  which  wall 
of  the  uterus  a  tumour  springs,  as  the  tumour  and  the  fundus  may  appear 
similar  in  size  and  consistence.  In  these  cases,  however,  the  passage 
of  the  sound  into  the  uterine  cavity  will  decide  the  matter  at  once. 

A  small  growth  on  the  posterior  uterine  wall  is  most  easily  palpated 
by  rectal  examination,  with  simultaneous  dragging  downwards  of  the 
uterus  by  means  of  a  volsella.  In  this  situation  a  small  libroid  may  be 
mistaken  for  an  ovary,  prolapsed  and  fixed  in  the  retro-uterine  pouch  ; 
by  a  similar  method  of  examination  the  absence  of  tenderness  on  press- 
ure, and  the  presence  of  the  ovaries  in  another  situation  can  be  ascer- 
tained, and  the  exact  condition  determined. 

When  associated  with  surrounding  intlammator}^  deposit,  the  diag- 
nosis of  small  fibroids  is  extremely  dilficult  and  often  impossible. 

Occasionally  small  tumours  of  the  lower  jjart  of  the  anterior  uterine 
wall  are  extremely  difficult  to  detect,  though,  nevertheless,  they  may 
give  rise  to  most  distressing  urinary  symptoms.  Digital  examination 
by  the  urethra  should  in  these  cases  be  practised,  as  in  many  cases  by 
this  means  alone  a  differential  diagnosis  can  be  obtained. 

Increase  in  the  size  of  the  uterine  cavity  is  usually  present  when  the 
uterine  attachment  of  the  tumour  is  well  marked,  although  in  rare  cases 
large  tumours  have  been  found  Avith  a  uterus  distinctly  atrophied. 

When  situated  between  the  layers  of  the  broad  ligament  and  fixed, 
and  at  the  same  time  displacing  the  uterus  to  one  or  other  side  of  the 
pelvis,  these  tumours  may  be  confounded  with  morbid  tubal  enlarge- 
ments and  cellulitic  deposits.  Under  these  circumstances  the  history 
of  the  case,  the  even  contour  of  the  mass,  and  the  comparative  absence 
of  pain  on  pressure,  tend  to  remove  the  obscurity  in  diagnosis. 

Tubal  gestation,  with  a  history  of  irregular  and  profuse  uterine 
haemorrhages,  may  be  distinguished  by  the  softness  of  the  uterus  and 
the  attached  swelling,  the  rapidity  of  its  development,  and  the  presence 
of  other  signs  of  pregnancy. 

Hydro-  pyo-  and  ha3raatosalpinx,  when  matted  by  adhesions  and 
surrounded  by  inflammatory  exudation,  may  present  a  great  resem- 
blance. But  the  absence  of  tenderness  on  pressure  and  the  enlargement 
of  the  uterine  cavity  will  assist  greatly  in  forming  a  correct  diagnosis. 
Cellulitic  deposits  are  frequently  to  be  distinguished  only  by  the  history 
of  pain  and  fever,  and  their  diminution  under  suitable  treatment.  From 
the  projection  of  the  tumour,  when  large,  into  one  or  other  iliac  fossa, 
where  it  is  immovably  fixed,  it  might  at  first  be  mistaken  for  a  growth 
of  the  ilium.  This  mistake  will,  however,  be  rectified  on  pelvic  exami- 
nation which  will  reveal  its  connection  with  the  uterus. 

Large  abdominal  tumours  are  frequently  associated  with  a  marked 
uterine  souffie,  and  may  thus,  from  their  shape  and  median  position, 
resemble  the  pregnant  uterus.  But  the  absence  of  amenorrhoea,  slow- 
ness of  growth  and  harder  consistence,  with  a  coexisting  want  of  mam- 
mary and  other  symptoms  and  signs  of  pregnancy,  should  prevent  any 
serious  misapprehension. 


58o  SYSTEM   OF  GYA'yECOLOGY 

From  ovarian  growths  fibroids  are  usually  to  be  distinguisbed  by 
their  harder  consistence  ;  although  I  have  seen  a  unilocular  parovarian 
cyst  so  tense  that  differentiation  by  this  means  was  impossible.  Other 
points  of  differential  importance  —  such  as  uterine  hcemorrhage, 
uterine  souffle,  increased  size  of  uterine  cavity,  and  the  nodular  outline 
of  the  tumour  —  may,  in  individual  cases,  assist  us  in  arriving  at  a  cor- 
rect conclusion  as  to  the  nature  of  the  growth;  tinfortunately  those, 
one  and  all,  are  as  frequently  absent  as  present.  AVlien  they  have 
undergone  secondary  cj^stic  change,  the  difficulty  of  diagnosis  of  fibroid 
from  ovarian  cystoma  is  still  further  increased,  and  in  many  cases 
laparotomy  alone  can  decide  the  matter. 

Solid  ovarian  fibroma,  from  its  rarity,  may  usually  be  set  aside  ; 
moreover,  in  the  majority  of  cases,  this  is  associated  with  ascites,  a 
condition  rarely  met  with  in  uterine  fibroid. 

Sabperitoneal  tumours  which  grow  downwards  into  the  pelvis  are 
fortunately  rare,  and  probably  arise  in  the  majority  of  cases  from  the 
supravaginal  cervix  with  the  signs  of  which  they  closely  correspond. 
They  usually  retain  a  broad  attachment  to  the  uterus,  and  from  their 
position  early  give  rise  to  severe  and  distressing  pressure  symptoms. 

As  has  already  been  shown,  fibroids  are  extremely  difiicult  to  diagnose 
when  small.  When  posterior  they  tend  to  lift  the  uterus  upwards  behind 
the  pubic  symphysis,  and  at  the  same  time  they  fill  up  the  recto-uterine 
and  recto-vaginal  space,  where  they  may  be  felt  as  a  hard  fixed  mass, 
bulging  the  posterior  fornix  and  posterior  vaginal  wall.  They  may  be 
closely  simulated  by  incarcerated  subperitoneal  tumours  ;  but  these  are 
usually  more  or  less  movable  on  pressure,  and  present  a  distinct  sulcus 
between  the  uterus  and  the  growth.  In  most  cases  tumours  which  arise 
low  in  the  uterus  tend  to  shorten  the  intravaginal  cervix ;  by  this  prop- 
erty they  can  usually  be  diagnosed  from  the  incarcerated  fibroids  of 
the  upper  part  of  the  uterine  body  and  fundus. 

Interstitial  Fibromyoma.  —  The  primary  nodule  in  this  variety  always 
originates  in  the  middle  layers  of  the  uterine  muscle,  but  has  no  special 
tendency  to  grow  or  to  be  driven  in  any  one  direction.  Thus  when  of 
any  size,  it  equally  bulges  the  mucosa  inwards  and  the  peritoneum  out- 
wards ;  or,  in  other  words,  it  is  surrounded  on  all  sides  with  a  layer  of 
uterine  muscle  of  equal  thickness  which  forms  the  capsule;  it  may  be 
practically  considered,  therefore,  as  a  simple  localised  thickening  of  the 
uterine  wall. 

These  gi-owths  form  a  connecting  link  between  the  submucous  and 
subperitoneal  varieties,  the  characters  of  either  of  which  they  may 
secondarily  assume,  as  already  described.  They  produce  the  effects  of 
both  varieties  on  the  size  and  position  of  the  uterus ;  simulating  on  the 
one  hand  the  submucous,  by  causing  enlargement  of  the  uterine  cavity, 
and  at  the  same  time,  if  of  large  size,  displacing  the  organ  after  the  manner 
of  the  subperitoneal.  It  will  thus  be  seen  that  an  absolute  distinction 
between  the  described  varieties  is  im])Ossil)le,  as  the  one  drifts  insensi- 
bly into  the  otlier.    For  clinical  description,  h(jwever,  the  classification  is 


BENIGN   GROWTHS   OF   THE    UTERUS  581 

useful.  The  growth  of  the  intramural  variety  is  disposed  to  be  more 
rapid,  as  its  nourishment  from  the  highly  vascular  capsule  is  less  liable  to 
be  interfered  with  than  in  the  other  forms.  From  their  freer  circulation 
and  more  rapid  growth  they  are  usually  more  highly  myomatous  than  the 
other  varieties,  and  have  thus  a  softer  consistence.  Hard  fibrous  nodules 
are  also  very  commonly  met  with. 

Their  direction  of  growth,  though  frequently  abdominal,  is  prone  to 
be  intraligamentary  and  pelvic.  They  tend,  therefore,  soon  to  give  rise 
to  pressure  symptoms.  They  may  attain  enormous  dimensions  in  a  com- 
paratively short  time,  and  are  particularly  liable  to  secondary  a^dematous 
changes.  From  the  multiple  tendency  of  fibroids,  examples  of  each 
variety  may  be  simultaneously  present  in  the  same  uterus;  each  more 
or  less  masking  the  characteristics  of  the  other.  It  is  by  no  means 
uncommon  to  find  a  submucous  polypus  associated  with  both  large  peri- 
toneal and  interstitial  growths.  It  is  in  fact  the  exception  for  them  to 
grow  singly. 

Symptoms.  —  Being  the  connecting  link  betAveen  the  subperitoneal  and 
submucous  forms,  the  symptoms  of  intramural  growths  are  more  or  less 
a  combination  of  those  of  both  the  former.  Thus  on  the  one  hand,  like 
the  submucous,  they  frequently  give  rise  to  haemorrhage,  dysmenorrhoea, 
leucorrhoea ;  and  at  the  same  time  they  are  associated  with  the  marked 
pressure  symptoms  characteristic  of  the  subserous.  It  must  be  mentioned, 
however,  that  haemorrhage,  though  a  common  symptom  of  this  variety, 
is  by  no  means  invariably  met  with,  even  though  the  tumour  be  of  large 
size  and  associated  with  great  enlargement  of  the  uterine  cavity. 

Being  always  surrounded  by  a  well-marked  vascular  capsule,  from 
which  the  nutrition  of  all  fibromyomas  is  derived,  they  naturally  tend 
to  grow  with  greater  rapidity  and  to  reach  enormous  dimensions.  AVhen 
large  they  are  always  associated  with  a  marked  uterine  souffle.  AA'hen 
extremely  small  their  symptoms  and  signs  are  practically  identical  with 
those  of  metritis  and  endometritis,  namely,  haemorrhage,  with  enlargement 
of  the  uterus  and  its  cavity ;  and  from  this  it  is  impossible  to  distinguish 
them.  When  of  considerable  proportions  the  regular  globular  increase 
of  the  uterus  can  be  made  out  without  difficulty.  They  may  now  be 
mistaken  for  submucous  growths ;  but  usually  the  haemorrhage  is  not  so 
severe,  and  the  sound  passes  into  the  uterine  cavity  without  difficulty. 
If  any  difficulty  in  diagnosis  should  remain,  digital  examination  of  the 
uterine  cavity  after  cervical  dilatation  will  at  once  decide  the  nratter. 

When  small  the  uterus,  from  increased  weight,  is  low  in  the  pelvis  ; 
but  when  larger  than  a  four  months'  pregnancy  the  uterus  is  pulled  up, 
and  the  vagina  is  elongated. 

From  the  presence  of  a  uterine  souffle,  and  the  frequently  associated 
blue  discoloration  of  the  vulva,  these  tumours  may  at  first  sight  be 
mistaken  for  pregnancy ;  but  this  error  should  at  all  times  be  easily 
avoided  by  having  regard  to  the  menstrual  history,  the  rate  of  growth, 
the  softness  of  the  vagina  and  of  the  tumour,  and  the  absence  of  mammary 
changes. 


582 


SYSTEM  OF  GYNECOLOGY 


Fibromyoma  of  Cervix.  —  As  lias  already  been  noted,  cervical 
fibroids  are  much  less  frequent  than  those  of  the  body  and  fundus  viteri ; 
and  though  in  this  situation  they  are  identical  in  their  development  and 
mode  of  growth  with  the  latter,  their  clinical  character  is  so  distinct  as 
to  require  separate  description. 

As  Duchemin  has  shown,  an  interstitial  nodule  of  the  uterine  body 
may  from  a  downward  direction  of  growth  become  secondarily  entirely 
cervical.  At  the  same  time,  a  tumour  may  by  growth  upwards  and  down- 
wards combine  the  characteristics  of  the  cervical  and  corporeal  varieties. 
I  had  a  well-marked  example  of  this  class  under  my  own  care,  where  a 
tumour  distinctly  felt  at  the  level  of  the  umbilicus  was  protruded  at  the 
same  time  through  the  vulva.  On  account  of  its  enormous  dimensions 
removal  by  morcellation  was  performed,  as  it  was  expected  that  two 
growths  might  be  present,  —  the  one  a  large  submucous  polypus,  and  the 
other  interstitial  or  subserous.  After  removal,  however,  of  the  vaginal 
portion,  the  anterior  cervical  lip  was  found  tightly  stretched  over  the 
tumour  which  formed  one  mass,  involving  the  posterior  cervical  lip  and 
the  posterior  wall  of  the  uterine  body. 


Fig.  149.  —  Submucous  intravafiinal  cervical 
fibroid.     (Alter  Schroeiler.) 


Fig.  150.  —  Subserous  cervical  fibroid,  tilting: 
uterus  above  pubes  and  bulgring  posterior 
vairinal  wall. 


Cervical  fibromyomas  may  be  submucous,  interstitial,  or  subserous. 

The  submucous  varieties  may  be  stalked  or  sessile,  and  they  usually 
project  into  the  vagina.  They  are  rarely  bigger  than  the  egg  of  a  goose, 
but  they  may  be  large  enough  to  fill  the  whole  true  pelvis  (l^'ig.  149). 
They  tend  to  cause  prolapsus  uteri,  and  may  closely  simulate  inversion 
of  the  fundus,  the  os  uteri  being  frequently  most  difficult  to  find. 
They  are  rarely  found  to  grow  from  the  vaginal  aspect  of  the  free 
cervix. 

When  subserous  tliey  necessarily  ;irisc  from  tlie  sui)ravaginal  cervix, 
and  Ijurrow  amongst  the  pelvic  tissues  in  which  they  become  immovably 


BENIGN  GROWTHS   OF  THE    UTERUS  583 

fixed ;  thus  they  may  give  rise  to  grave  and  distressing  pressure  symptums 
at  an  early  stage.  They  are  most  frequently  met  with  posteriori}-,  and 
may  burrow  downwards  between  the  vagina  and  rectum,  so  as  to  be  felt  on 
examination  bulging  the  posterior  vaginal  wall  (Fig.  150).  In  some  cases 
where  the  tumour  is  larger,  the  uterus  is  tilted  high  above  the  symphysis 
pubis,  and  the  cervix  may  be  quite  out  of  the  reach  of  the  examining 
finger  in  the  vagina.  They  also  grow  laterally  between  the  layers  of  the 
broad  ligament ;  here  they  are  usually  sessile,  though  stalked  examples 
have  been  described  in  this  situation  by  Gemmel  and  Mallet.  They 
rarely  fill  the  utero-vesical  septum,  but  when  in  this  position  they  soon 
give  rise  to  extremely  distressing  urinary  trouble. 

Interstitial  cervical  fibroids  are  extremely  rare.  From  their  fixed 
position  they  completely  obliterate  the  vaginal  fornix,  and  so  stretch  and 
thin  the  opposing  cervical  lip  that  the  os  uteri  is  frequently  only  to  be 
made  out  with  the  utmost  difficulty  as  a  narrow  slit.  The  utero-vaginal 
relations  are  thus  completely  altered,  and  on  examination  the  vaginal 
roof  appears  to  be  blocked  by  a  hard  resistant  mass,  with  the  free  cervix 
absent  and  no  apparent  os  uteri.  They  give  rise  early  to  pressure 
symptoms,  especially  if  situated  in  the  anterior  cervical  lip. 

When  submucous  they  are  generally  associated  with  much  leucorrhoea 
and  feeling  of  pelvic  weight;  but,  being  free  from  the  uterine  cavity, 
they  seldom  give  rise  to  the  hamorrhages  which  characterise  polyi)i  of 
the  uterine  body.  They  may,  however,  cause  severe  dysmenorrlioja  from 
obstruction  to  the  menstrual  flow. 

When  small  their  diagnosis  is  self-evident ;  but  when  large  and  filling 
the  vagina  their  attachment  is  often  impossible  to  trace,  and  they  may 
thus  be  mistaken  for  a  fundal  fibroid  with  inversion,  as  a  thorough  bi- 
manual examination  of  the  uterus  and  the  use  of  the  uterine  sound  are 
im  possible.  From  their  occasional  broad  attachment,  involving  the  entire 
lip  of  the  free  cervix,  they  appear  to  rise  directly  from  the  vaginal  wall, 
and  have  been  mistaken  for  vaginal  fibromyomas. 

Treatment.  —  When  submucous  and  stalked,  their  removal  is  to  be 
performed  in  the  manner  described  for  polypi.  When  sessile  their 
enucleation  is  usually  an  easy  matter. 

When  interstitial  or  subserous,  however,  their  removal  may  bo  l)y  no 
means  simple,  and  is  only  to  be  attempted  if  they  give  rise  to  serious 
symptoms.  In  this  position  they  are  unusually  slow  in  their  growth, 
and  I  have  seen  several  cases  where  they  seemed  to  undergo  no  change, 
antl  remained  innocuous  during  several  years. 

If,  however,  symptoms  indicate  pressure,  absolute  removal  only  is 
of  any  value  so  far  as  my  experience  goes.  Electricity  and  ergot  are 
practically  valueless. 

Extirpation  of  the  growth  by  enucleation  or  morcellation  per  vaginam, 
as  described  p.  (504,  can  be  performed  with  much  safety. 

Growth  and  course  of  Fibromyoma.  — The  rate  of  growth  of  fibro- 
myomata  is  extremely  variable.  In  many  carefully  observed  instances 
they  have  been  known  to  remain  for  years  practically  stationary;  while 


5S4  SYSTEM   OF  GYNECOLOGY 

in  others  large  tumours  have  been  knoAvn  to  develop  Avithin  a  few  months. 
In  general,  however,  their  growth  is  comparatively  slow. 

Their  rate  of  increase  is  naturally  proportionate  to  the  means  of 
nourishment ;  and  as  this  is  entirely  derived  from  the  vessels  of  the  cap- 
sule, it  necessarily  follows  that  thoroughly  encapsulated  tumours,  such  as 
the  interstitial,  tend  to  grow  much  more  rapidly  than  those  in  which  the 
capsule  is  partial  or  atrophied  from  pressure.  In  like  manner  tumours 
which  are  free  from  pressure  develop  more  rapidly,  which  accounts  for 
the  usually  large  size  and  more  rapid  growth  of  the  subserous  and  in- 
terstitial varieties  as  compared  with  the  submucous. 

Sudden  and  rapid  enlargement  may  occur  ;  but  this  is  usually  due  to 
secondary  changes  such  as  oedema  or  hsemorrhage  into  the  substance  of 
the  tumour.  Temporary  enlargement  due  to  increased  vascularity  is 
manifest  during  menstruation  and  pregnancy ;  but  it  is  probable  that 
during  the  latter  event  a  certain  amount  of  increase  remains,  although, 
in  many  examples,  involution  and  uterine  contraction  during  the  puer- 
periura  cause  actual  diminution,  as  the  result  of  retrograde  changes. 

After  the  menopause  active  growth  commonly  ceases,  and  the  tumours 
tend  to  atrophy,  or  at  least  to  remain  quiescent ;  rapid  enlargement  may, 
however,  occur  after  this  period  as  the  result  of  secondary  metamorphosis. 

On  account  of  the  increased  vascularity  of  the  uterus  due  to  the 
presence  of  tumours  the  menopause  is  usually  delayed.  Thus  active 
growth  may  continue  till  the  patient  is  well  over  fifty  years  of  age,  a 
point  of  great  importance  in  prognosis. 

The  actual  changes  which  occur  in  the  tumour  after  the  climacteric 
is  one  of  progressive  induration,  due  to  atrophy  of  the  muscular  ele- 
ments from  diminished  blood-supply. 

Secondary  Changes.  —  These,  as  regards  the  size  of  the  tumours, 
may  be  considered  as  either  retrogressive  or  progressive.  The  former 
are  represented  by  atrophy  and  degeneration  —  fatty  or  calcareous  ;  the 
latter  by  oedema,  cystic  formation,  inflammation,  and  infiltration  by 
embryonic  cells. 

Atrophy.  —  This,  the  usual  event  after  the  menopause,  may  occur  dur- 
ing the  sexual  period ;  and  may  extend  from  a  slight  diminution  in  size 
to  complete  disappearance  of  the  growth.  The  latter,  though  rare,  has 
been  noted  by  such  close  and  competent  observers  that  no  doubt  exists 
as  to  its  actual  occurrence.  Thus  Bantock  relates  an  interesting  example 
in  the  Britifih  Gyncecolof/ical  Jotirnal,  and  Schroeder  (55)  has  collected 
and  observed  a  large  number  of  cases. 

Slight  diminution  is,  in  the  vast  majority  of  cases,  associated  with 
evident  hardening  of  the  tumour,  and  is  due  to  the  excessive  develop- 
ment of  the  filjrous  tissue  at  the  expense  of  the  muscular;  a  process 
induced  by  diminution  in  the  blood-supply,  which  may  be  due  either  to 
excessive  pediinctilation  or  to  pressure. 

The  prcKiess  by  which  actual  absorption  is  brought  about  is  more  diffi- 
cult to  determine.  It  is  probable  that,  in  some  cases  at  least,  oedcmatous 
infiltration  may  be  the  precursor  of  such  a  result ;  as  the  softening  of  the 


BENIGN  GROWTHS   OF   THE    UTERUS  585 

tissue  generally,  the  associated  swelling  and  degeneration  of  the  individ- 
ual cells,  and  the  disappearance  of  their  nuclei,  point  to  a  retrogressive 
change  w^hich  may  lead  to  complete  obliteration. 

The  probable  factor  in  the  production  of  the  oedema  is  a  contraction 
of  the  muscular  wall  of  the  uterus  which, from  compression  of  the  tumour, 
interferes  with  the  blood  return.  This  probability  is  strongly  supported 
by  the  fact  that,  in  the  majority  of  cases  recorded,  the  absorption  occurred 
after  pregnancy  or  subsequent  to  treatment  by  electricity,  ergot,  or  re- 
moval of  the  ovaries,  all  of  which  means  are  undoubtedly  associated 
with  much  uterine  contraction.  Thoroughly  encapsulated  tumours  are 
therefore  more  readily  influenced  in  this  manner. 

Further  proof  of  the  effect  of  excessive  contraction  of  the  puerperal 
uterus  is  to  be  found  in  the  many  cases  cited  where  actual  sloughing  of 
the  tumour  has  followed  delivery. 

Calcification  is  due  to  the  deposit  of  carbonate  and  phosphate  of  lime 
in  the  fibrous  tissue  of  tumours  which  have  ceased  to  grow,  and  gives 
rise  to  the  so-called  ''  womb-stones."  It  is  most  frequently  met  with  in 
the  tumours  of  elderly  women,  in  which  after  the  menopause  atrophy  and 
induration  have  supervened.  When  present  before  the  menopause, 
which  is  unusual,  it  is  generally  found  in  stalked  subserous  growths  in 
which  the  means  of  nourishment  are  extremely  slender.  In  elderly 
women,  however,  all  varieties  of  fibromyoma  are  liable  to  this  change. 

Calcification  may  be  present  in  either  of  two  forms,  peripheral  or  in- 
terstitial. In  the  former  and  rarer  variety,  a  thin  rough  chalky  deposit 
is  found  on  the  surface  of  the  growth  only ;  in  the  latter  there  is  an 
infiltration  of  lime  salts  throughout  the  thickness  of  the  growth,  Avhich 
may  be  localised  in  patches  or  invade  its  mass.  So  dense  may  this 
deposition  be,  that  the  surface  of  the  cut  sections  can  be  polished  like 
ivory.  When  peripheral  calcification  is  complete,  the  centre  of  the 
tumour  iisually  becomes  necrotic  from  the  complete  arrest  of  its 
circulation. 

Many  examples  of  the  interstitial  type  have  been  described,  but  the 
submucous  are  but  rarely  met  with  ;  one  of  the  largest  calcified  tumours 
described  weighed  2  lbs.  5|  ozs.,^  and  was  found  in  a  grave,  within  the 
pelvis  of  an  apparently  elderly  woman. 

Thesecalcifiedtumours  have  been  knownanddescribed  by  Hippocrates 
and  other  ancient  authors,  since  which  time  records  of  51  published  cases 
have  been  collected  by  Cruveilhier.  According  to  some  authors,  the 
secondary  change  is  an  ossification,  and  the  presence  of  true  osteophytes 
has  been  recorded  by  Freund.  In  the  majority  of  cases,  however,  it  is 
mere  calcification. 

Fatty  degeneration  is  of  extreme  rarity.  Examples,  however,  are 
described  by  Turner  and  Hewitt  {Q>Q>) ;  and  a  specimen,  described  by 
Sir  James  Paget,  is  to  be  found  in  St.  Bartholomew's  ]\ruseum  (Series 
33,  No.  74). 

Larclaceous  degeneration  is  described  in  a  unique  case  quoted  by  Stratz. 
1  Spec.  1799,  Edinburgh  Anat.  Museum. 


586  SYSTEM   OF  GYNECOLOGY 

Colloid  and  myxomatous  changes,  on  the  other  hand,  are  comparatively 
frequent ;  but  as  they  are  intimately  associated  Avith  the  cystic  changes 
later  to  be  described,  consideration  of  them  may  be  deferred. 

Malignant  degeneration  and  infiltration  of  fibromyoma  is  entirely  con- 
fined to  the  connective  tissue  or  sarcomatous  type  ;  it  is  probable,  indeed, 
that  all  encapsulated  sarcomas  are  originally  fibromyomas  secondarily 
infiltrated.     Carcinoma  never  occurs  in  fibroids. 

Spontaneous  sloughing,  or  "necrobiosis,"  as  it  is  termed  by  some  au- 
thors, has  been  met  with  either  partial  or  complete,  and  unassociated  with 
septic  influences  or  gangrene ;  it  is  due  to  a  sudden  and  complete  arrest 
of  the  circulation  through  the  tumour,  resulting  from  a  twisted  pedicle 
or  sustained  compression.  When  due  to  the  former,  it  is  associated  Avith 
symptoms  of  pain,  fever,  and  peritonitis,  similar  to  those  occurring  Avith 
a  twisted  pedicle  in  ovarian  tumours.  True  gangrene,  however,  is  much 
more  frequent.  This  is  particularly  apt  to  occur  in  submucous  groAvths 
which,  after  the  complete  arrest  of  their  circulation  by  uterine  contrac- 
tion or  cervical  constriction,  become  exposed  to  the  influence  of  septic 
organisms  entering  by  some  ulceration  or  abrasion  in  the  capsule.  In 
this  manner  complete  and  rapid  disorganisation  of  the  tumour  results; 
the  growth  may  be  sloAvly  expelled.  The  expulsion  is  ahvays  associated 
with  a  vaginal  discharge  of  an  intensely  foetid  charat^ter.  In  many  in- 
stances the  termination  is  favourable  to  the  patient,  although,  of  course, 
death  may  ensue  from  general  septic  infection.  Artificial  attempts  to 
bring  about  this  natural  process  of  cure  by  destruction  of  the  capsule 
have  been  made,  although  generally  Avith  most  disastrous  consequences. 

Suppuration  and  abscess  formation  is  the  most  frequent  result  of 
ulceration  or  destruction  of  the  capsule,  Avhether  due  to  such  interference 
as  curettage,  or  the  introduction  of  tents  or  other  instruments  for  diag- 
nostic purposes,  or  to  natural  causes.  It  may,  hoAvever,  occur  rarely  in 
subperitoneal  and  interstitial  tumours,  where  no  external  interferences 
can  be  ascertained.  Examples  of  such  have  been  recorded  by  Lee, 
Lisfranc,  and  Jonas ;  and  in  a  case  of  Bernays,  treated  by  laparotoni}^ 
the  enormous  amount  of  six  gallons  of  pus  was  evacuated  from  a  sub- 
peritoneal growth. 

That  true  suppuration  can  occur  Avithout  direct  inoculation  by  organ- 
isms is  perhaps  contrary  to  the  weight  of  present  pathological  teaching; 
it  is  important,  therefore,  carefully  to  examine  the  pus  in  those  obscure 
cases  in  order  to  ascertain  the  presence  or  absence  of  organisms. 

A  number  of  cases  have  been  recorded  by  Hall  and  others  in  which 
suppuration  of  flbroids  occurred  during  the  puerperium,  the  result,  no 
doubt,  of  se^jtic  absoi'ption  from  the  placental  site,  or  from  bruises  caused 
by  labour. 

(Jlfstic  Changes  in  Fibromyoma.  —  Whether  from  a  pathological  or 
clinical  aspect,  the  fibrocystic  varieties  of  uterine  tumours  are  most 
interesting.  On  the  one  hand  their  clinical  course  and  physical  signs  are 
often  so  variable  and  ill-defined  that  they  baffle  detection,  even  at  the 
hanfls  of  the  nicest  competent  diagnostician  ;  Avhilc  their  d(!velopment  and 


BENIGN   GROWTHS    OF   THE    UTERUS 


5S7 


structure  has  beeu  and  indeed  is  still  the  theme  of  fruitful  discussion 
amongst  pathologists. 

Pathologically,  they  may  generally  be  considered  as  due  to  secondary 
changes  in  previously  existing  iibromyomas,  though  at  the  same  time  it 
cannot  be  definitely  asserted  that  they  never  arise  da  novo. 


Fio.  151.  —  Advnncpd  fibrocystic  dcfreneration  of  stalked  ."subperitoneal  fibroid,  with  partially  twisted 
pedicle.  From  preparation.  Half-size.  Showing  partial  degeneration  and  ventricular  appearance 
of  cyst  wall. 

Three  Avell-markcd  forms  of  secondary  cystic  development  must  be 
clearly  distinguished  :  firstly,  that  due  to  simple  degenerative  changes 
only,  which  may  be  either  fatty  or  the  result  of  necrobiosis,  as  already 
described ;  secondly,  that  due  to  a  primary  infiltration  with  secondary 
degeneration,  which  forms  by  far  the  most  common  and  interesting 
group;  and,  thirdly,  a  rare  variety  due  to  the  cavernous  distension  of 
the  blood-vessels  in  the  tumour. 


588 


SYSTEM  OF  GYXyECOLOGY 


Though  the  detailed  pathological  appearances  may  have  various  minor 
differences  in  individual  cases,  the  infiltrative  varieties  are  characterised 
by  a  primary  serous  infiltration  and  associated  myxomatous  softening 
of  the  growth,  accompanied  by  an  oedematous  swelling  of  the  connective 
tissue,  followed  by  more  or  less  disintegration.  When  advanced,  these 
changes  result  in  the  formation  of  spaces  or  false  cysts  filled  with  fluid, 
the  walls  of  which  are  formed  by  the  non-disintegrated  portion  of  the 
tumour.  At  this  stage  the  muscular  bundles,  being  still  present,  prevent 
the  formation  of  large  cavities,  and  give  to  the  cyst  wall  a  peculiar  uneven 
appearance,  closely  simulating  the  cardiac  cavities  with  their  columna? 
carnese.  Subsequently,  however,  the  muscle  also  becomes  disintegrated 
and  large  spaces  are  formed  (Fig.  151).     The  contained  fluid  in  the  large 


Fig.  152.  —  Qildematous  inter.stitial  cystic  fibroinyoma.     Drawn   from   preparation. 
U,  Uterus  enlarg-ed  to  7  inclies  in  cavity  ;  C,  cyst  in  tumour. 


One-third  size. 


cysts  varies  from  a  pale  amber  to  a  dark  porter  colour,  the  change  in 
colour  being  due  to  the  extravasation  of  blood.  In  most  instances  the 
fluid  on  evacuation  spontaneously  coagulates ;  this  is  due  to  its  highly 
albuminous  nature,  the  exuded  serum  being  highly  charged  with  the 
products  of  tissue  disintegration.  Chemical  and  microscopic  examination 
show  it  to  contain  serum-albumin  and  fibrin,  with  more  or  less  mucin, 
blood,  and  detritus  from  degenerated  tissue.  In  the  early  stages  the 
fluid  is  almost  entirely  composed  of  serum-albumin. 

The  degenerative  process  may  be  confined  to  definite  portions  of  the 
tumour,  with  intervening  areas  of  higher  grades  of  tissue  ;  but  in  some 
instances  the  disintegration  is  so  complete  that  a  unilocular  cavity  is 
formed,  boundfid  only  by  the  pre-existing  caj)sule  of  the  tumour  (Kieux). 

In  the  early  stages  the  cut  surface  may  have  a  checkered  appearance, 
some  portions  having  the  characters  of  an  ordinary  fibromyoma,  others 
showing  softened  areas  of  apparently  myomatous  tissue,  while  dotted  here 


BENIGN  GROWTHS   OF  THE    UTERUS 


589 


and  there  may  be  seen  small  cysts,  varying  in  size  from  a  pinhead  to  a 
grape.  In  other  instances  the  entire  growth  is  uniformly  softened,  and 
from  its  surface  there  exudes  on  section  a  clear  yellowish  fluid,  which 
from  its  escape  causes  a  marked  diminution  in  the  size  of  the  tumour. 
•In  this  stage  these  growths  are  described  as  oedematous  fibroids.  In  a 
somewhat  more  advanced  stage  a  number  of  cavities  filled  with  fluid 
will  be  seen  scattered  throughout  (Fig.  152).  The  entire  growth  may 
with  great  ease  be  enucleated  from  its  surrounding  capsule. 

Microscopically,  in  the  early  stages,  the  structure  is  seen  to  be  fibro- 
muscular :  the  intermuscular  fijjrous  and  connective  tissue  is  swollen  and 
myxomatous,  while  the  intercellular  spaces  are  distended  with  fluid. 
Leopold  and  Fehling,  and  Ehein  have  described  an  endothelial  lining 
forming  the  walls  of  the  dilated  intercellular  spaces,  which  they  recognised 
as  lymph  channels,  and  accordingly  designated  the  tumour  cysto-lym- 
phaugiectodes ;  but  in  cases  described  by  Gusserow  (26)  and  Spiegelberg 
no  such  lining  was  apparent.  Out  of  five  well-marked  examples  which  I 
have  carefully  examined,  in  only  one  have  I  found  evidence  of  spaces 
lined  with  endothelium,  and 
in  this  one  but  a  few  small 
patches  scattered  through- 
out a  large  tumour  (7  lbs.) 
(Fig.  153). 

Examination  of  the  cyst 
wall  of  advanced  cases  failed 
to  show  any  true  lining.  In 
two  cases  of  very  rapidly 
growing  interstitial  tumours 
of  this  type,  the  microscope 
showed  a  large  number  of 
round  and  spindle-shaped 
cells  situated  between  the 
bands  of  muscle  fibres,  while 
throughout  the  entire  mass 
were  isolated  large  round 
cells  of  an  endothelial  char- 
acter. In  all  the  cases  ex- 
amined blood  extravasations  were  found  scattered  through  the  growth. 

From  the  appearances  presented  there  is  but  little  doubt  that  in  these 
tumours  we  have  to  deal  with  a  serous  infiltration  or  chronic  oedema  of 
pre-existing  fibromyoma,  which  results  either  in  a  simple  degeneration 
of  a  myxomatous  nature,  with  disintegration  and  cyst  formation,  or  is 
associated  with  active  connective  tissue  cell  proliferation. 

The  latter,  from  its  appearance,  seems  to  border  on  malignancy;  and 
it  is  probable  that  some  such  tumours  may  actually  become  myxo- 
sarcomatous  ;  but  in  the  majority  of  cases  they  are  unlikely  to  give  rise 
to  secondary  metastases,  and  they  do  not  tend  to  recur  after  removal.  It 
is  almost  certain  that  the  cause  of  both  varieties  is  the  same,  namely, 


Fig.  15.3.  ■ 


Microphotog^r.iph  of  adematous  iibroid,  showing 
endothelial  lined  spaces,     x  ISO. 


590  SYSTEM  OF  GYNECOLOGY 

interference  with  the  venous  return  —  a  condition  by  no  means  difficult 
to  account  for  when  one  considers  the  usual  sluggish  circulation  of 
fibroids  generally :  this  view  is  corroborated  by  the  constant  appear- 
:ince  of  areas  of  blood  extravasation  throughout  the  oedematous  tissue. 
The  process  must  then  be  regarded  as  one  of  chronic  oedema. 

That  this  obstruction  is  more  complete  in  some  cases  than  others, 
accounts  for  the  colour  presented  by  the  growth,  which  varies  from  a  light 
pink  to  a  deep  purple.  In  the  latter  case  one  seldom  fails  to  find  throm- 
bosed vessels  scattered  throughout  it.  The  immediate  cause  of  impairment 
in  the  circulation  is  most  frequently  to  be  found  in  the  capsule ;  thus 
interstitial  tumours  are  by  far  the  most  frequently  affected.  The  tumour 
may  grow  rapidly  without  sufficient  dilatability  of  its  surrounding  capsule, 
or  be  compressed  by  the  active  contraction  of  the  thick  muscular  sur- 
roundings. In  these  cases  the  entire  tumour  is  affected  uniformly.  It 
may  also  be  met  with  in  stalked  subserous  tumours  as  the  result  of 
blockage  to  the  circulation  in  the  pedicle.  This  is  beautifully  demon- 
strated, in  the  preparation  from  which  Fig.  9  was  drawn,  as  the  result 
of  a  partial  twist  of  the  pedicle ;  in  these  cases  the  change  may  be  par- 
tial only,  and  is  usually  more  acute,  large  cysts  being  rapidly  formed 
and  extensive  haemorrhages  usually  occurring.  In  submucous  polypi 
oedema  is  of  course  extremely  common,  but  their  expulsion  is  usually 
completed  before  large  cysts  are  developed ;  or,  from  subsequent  com- 
plete arrest  of  the  circulation,  sloughing  and  gangrene  occur. 

From  a  clinical  aspect  fibrocystic  tumours  are  extremely  interesting. 
In  the  early  stages  they  have  a  soft,  boggy  consistence  which  is  apt  to 
be  mistaken  for  fluctuation.  In  the  later  stages,  when  large  cavities 
are  present,  fluctuation  may  be  made  out ;  though  from  the  thickness 
of  their  walls  this  is  by  no  means  definite,  even  when  the  cavities  are 
of  considerable  size. 

Large  cysts  are  specially  likely  to  occur  in  pedunculated  subserous 
growths ;  indeed,  in  fifty  cases  collected  by  Heer,  five  only  were  inter- 
stitial and  two  submucous.  Coussat  describes  a  fibrocyst  of  the  cer- 
vix. Cullingworth  (13)  describes  a  similar  condition  in  which  the 
tumour  weighed  over  6  lb.,  and  developed  rapidly  after  the  menopause. 

On  the  other  hand,  in  interstitial  tumours  simple  oedematous  change 
without  the  formation  of  large  cavities  vastly  preponderates.  As  I  have 
already  pointed  out,  this  change  is  almost  always  met  with  in  solitary 
tumours  ;  although  in  one  case  I  observed  small  secondary  nodules  in  the 
uterine  wall.  Their  growth  is  more  rapid  than  that  of  simple  fibroids, 
but  usually  slower  than  that  of  a  glandular  ovarian  cystoma;  though 
there  are  many  exceptions  to  this  rule.  They  may  attain  an  enormous 
size,  examples  of  80  lbs.  weight  having  been  recorded.  From  the  occa- 
sional rupture  of  large  vessels  in  their  interior  also  they  may  rapidly 
assume  large  proportions.  In  a  case  cited  by  liouth  several  such  rupt- 
ures were  said  to  be  distinctly  felt  by  the  patient.  Sudden  and  definite 
enlargement  from  haimorrhage,  conimon  in  these  tumours,  may  be  also 
met  with  in  ovarian  cysts. 


BENIGN   GROWTHS   OF   THE    UTERUS  591 

Cystic  degeneration  may  occur  at  any  age,  and  the  subsequent  growth 
of  the  tumour  seems  to  be  uninfluenced  by  the  ovaries.  Thus  cystic  and 
cedematous  tumours  may  first  give  indications  of  their  presence  after  the 
climacteric ;  moreover,  they  are  in  no  way  influenced  by  removal  of  the 
uterine  appendages :  these  are  material  points  of  difference  when  com- 
pared Avith  simple  fibromyoma. 

According  to  their  locality,  like  simple  fibromyoma,  they  may  or 
may  not  be  associated  with  uterine  haemorrhage  ;  but,  as  they  are  most 
frequently  interstitial  or  subserous,  this  symptom  is  seldom  prominent. 

The  diagnosis  is  at  all  times  difficult,  and  particularly  so  in  the  stalked 
subserous  form  where  the  signs  may  be  identical  with  those  of  a  cystic 
ovarian  tumour.  The  symptoms,  as  we  have  seen,  are  by  no  means 
characteristic.  Although  special  attention  has  been  directed  by  Eouth 
and  Tait  to  the  general  absence  of  uterine  haemorrhage,  this,  however, 
is  doubtless  due  to  their  rarity  as  submucous  tumour. 

When  interstitial,  their  soft  consistence  and  rapidity  of  growth,  the 
usual  absence  of  uterine  haemorrhage,  and  the  associated  enlargement  of 
the  uterine  cavity  must  at  all  times  be  considered  suspicious  ;  while  if 
developed  after  the  menopause,  and  causing  painless  enlargement  of  the 
uterus  without  haemorrhage,  the  diagnosis  is  almost  assured.  In  like 
manner  when  a  large,  soft,  regular  uterine  growth  is  found  develoi^ing 
in  a  patient  under  thirty  years  of  age,  with  or  without  haemorrhage,  the 
presence  of  a  so-called  "  cedematous  fibroid  "  is  strongly  probable. 

Aspiration  has  been  recommended  in  order  to  ascertain  the  special 
characteristics  of  the  fluid  as  regards  coagulability,  and  so  forth.  Such  a 
procedure,  however,  cannot  be  too  severely  condemned :  firstly,  in  the 
early  stages  no  fluid  can  be  withdrawn ;  secondly,  so  extremely  feeble  is 
their  vitality  that  a  fatal  issue  may  be  caused  from  resulting  gangrene  of 
the  tumour ;  and  lastly,  as  removal  is  the  only  treatment,  whether  for  this 
condition  or  for  any  tumour  with  which  it  can  be  mistaken,  exploratory 
tapping  must  at  best  be  unnecessary.  It  may  further  be  stated  that 
spontaneous  coagulability  is  by  no  means  a  specific  character  although  it 
occurs  in  the  majority  of  cases.  A  uterine  souflle  is  evident  in  all  cases 
of  the  interstitial  kind ;  but  in  the  one  case  of  stalked  subserous  fibro- 
cystic I  have  seen  it  was  entirely  absent,  and  thus  could  not  be  dis- 
tinguished from  an  ovarian  cystoma. 

Another  variety  of  cystic  degeneration,  the  ''cavernous  angioma," 
though  pathologically  well  known,  is  extremely  rare  in  practice.  It  is 
characterised  by  the  abnormal  development  and  dilatation  of  the  blood- 
vessels of  the  growth,  a  change  which  may  involve  the  whole  tumour, 
or  be  localised  in  patches.  Virehow  (69)  first  drew  attention  to  its 
occurrence  and  named  the  condition  ''Myoma  telangiectodes."  On 
section  the  tumour  appears  as  a  spongy  mass  containing  a  large  number 
of  cavities,  which  vary  in  size  from  that  of  a  pinhead  to  a  pea,  and 
contain  soft  reddish  thrombi.  Subsequently,  from  rupture  of  these  small 
cysts,  with  resulting  coalescence,  larger  cavities  are  formed  with  irregular 
walls  which  closely  resemble  the  interior   of   the  cardiac  ventricles. 


592  SVSTEAf   OF  GYN^FICOLOGY 

Microscopically  the  characteristic  feature  is  the  innumerable  cavities 
filled  with  blood,  and  lined  by  endothelium ;  these  are  separated  from  each 
other  by  intervening  fibrous  and  muscular  tissue,  in  which  run  many 
capillaries.  Examples  have  been  recorded  by  Cruveilhier,  Lee,  AVeber, 
Leopold  and  others.  In  many  instances  they  are  clinically  to  be 
recognised  b}'  their  increase  at  the  menstrual  x^eriods,  and  their  subse- 
quent diminution. 

Two  examples  of  primary  origin  of  these  tumours  in  the  uterus  have 
been  recorded  by  Klob  (35)  and  Boldt. 

Though  but  few  angiomatous  tumours  have  been  met  with  and 
described,  it  is  probable  that  this  kind  of  secondary  change  may  form 
the  origin  of  a  considerable  number  of  fibrocystic  myomas;  as  it  is  well- 
known  that  angiomatous  growths  are  particularly  liable  to  undergo  a 
secondary  cystic  transformation.  Further,  the  appearances  presented 
by  cystic  angioma  in  other  situations  closely  simulate  those  met  with  in 
a  number  of  fibrocystic  growths  of  the  uterus. 

This  variety  of  cystic  change  may  also  be  associated  with  an  appar- 
ently sarcomatous  infiltration  of  the  growth  proper,  an  example  of 
which  is  described  by  Aslanian. 

A  close  connection  exists  between  this  variety  of  tumour  and  the 
ordinary  infiltrative  type  of  cystic  degeneration ;  for  though  in  the  early 
stages  they  may  appear  widely  dissimilar,  in  the  later  stages  of  large  cyst 
formation  and  degeneration  their  appearances  must  be  almost  identical ; 
moreover,  actual  cases  of  combined  lymphangiectoid  and  telangiectoid 
growths  have  been  described  by  Miiller. 

It  wall  thus  be  obvious  how  intricate  is  the  pathology  of  fibrocystic 
uterine  tumours,  and  how  tumours,  which  in  their  origin  appear  widely 
different,  may  subsequently  assume  identical  features.  It  is  probable 
that  their  rarity  to  a  great  extent  accounts  for  the  indefiniteness  of  our 
knowledge  of  their  development. 

Pregnancy  and  Fibromyoma. — As  already  stated,  there  can  be  little 
douljt  that  uterine  fibroids  as  a  class  tend  materially  to  prevent 
pregnancy,  and  are  a  direct  cause  of  sterility  both  relative  and  absolute ; 
equally  certain  is  it  that  their  position  in  the  uterine  wall  prevents  this 
function  to  a  greater  or  less  extent  as  the  tumour  approaches  the  uterine 
mucosa.  For  this  reason  the  submucous  type  is  most  closely  identified 
with  sterility ;  as  tlien  the  extreme  vascularity  of  the  mucosa  forms  an 
unfavouraVjle  seat  oi  implantation  for  the  impregnated  ovum,  and  one 
from  which  it  tends  to  become  separated  by  hemorrhage.  Sterility  is 
less  likely  to  occur  with  small  subserous  and  interstitial  tumours,  though 
distinctly  to  be  traced  in  some  cases ;  in  many  cases  it  is  due  to  the 
habitual  occurrence  of  abortion,  which  is  probably  induced  in  part  by 
the  difficulty  of  uterine  dilatation,  in  part  ]jy  the  tendency  to  hsemor- 
rhage  from  increased  vascularity. 

\\\  a  case  of  large  interstitial  fibroid  of  the  anterior  uterine  wall, 
which  came  under  my  own  oljservation,  the  dilatation  of  the  uterus  was 
so  interfered  with,  that  the  cavity  was  distended  in  the  form  of  an 


BENIGN  GROWTHS    OF   THE    UTERUS  593 

hour-glass;  the  placenta  was  situated  in  the  upper  compartment,  and 
the  foetus  grew  (till  the  18th  week)  in  the  lower.  After  abortion  it 
was  found  impossible  to  remove  the  placenta,  as  the  communication 
between  the  two  cavities  was  not  large  enough  to  admit  the  finger; 
death  occurred  from  septicaemia.  The  uterus  and  tumour  weighed  9 
lbs.     A  similar  case  is  described  by  Lusk. 

Should  gestation  proceed  to  full  term,  parturition  may  or  may  not  be 
interfered  with.  The  effect  naturally  varies  with  the  position  of  the 
growth :  when  low  in  the  uterus,  or  subserous  and  incarcerated  in  the 
pelvis,  it  may  form  an  insuperable  barrier  to  the  birth  of  the  child;  when 
higher  in  the  uterine  wall  they  frequently  cause  uterine  atony  and 
irregular  contractions,  with  their  accompaniments  of  delay  and  hcemor- 
rhage.  Submucous  pedunculated  tumours  frequently  present  in  front 
of  the  child. 

From  the  unequal  dilatation  of  the  uterine  cavity  malpresentations 
of  the  foetus  are  common.  Lefour  found  that  of  100  pregnancies  thus 
complicated  49  per  cent  were  preternatural  in  their  presentation. 
Winckel  estimates  breech  presentations  to  be  eight  times  more  common, 
and  transverse  to  be  increased  thirty-five-fold.  jMoreover  there  is  a 
decided  tendency  to  prolapse  of  the  cord;  and  undoubtedly  placenta 
praevia  is  more  frequently  met  with. 

Although,  frequently,  pregnancy  and  parturition  are  in  no  way 
affected  by  the  presence  of  fibroids,  it  must  be  acknowledged  that  their 
association  increases  the  risks  both  to  mother  and  child  in  proportion 
to  the  size  and  position  of  the  growth.  Susserot,  in  147  cases  of 
pregnancy,  shows  a  mortality  of  00  per  cent,  while  Pozzi  asserts  that  in 
interstitial  fibroids  of  large  size  the  mortality  is  as  high  as  53  jDCr  cent. 
Although  such  statistics  by  no  means  represent  the  general  mortality 
from  pregnancy  associated  with  fibroids,  they  are  of  value  in  demonstrat- 
ing the  possible  gravity  of  their  presence. 

Of  great  interest  also  is  the  effect  of  pregnancy  on  the  fibroids 
themselves.  With  its  occurrence  the  tumour  in  most  instances  rapidly 
increases  in  size,  the  enlargement  being  due  to  hypertrophy  of  the 
individual  muscular  fibres  of  the  tumour,  and  to  a  serous  infiltration  of 
the  intercellular  tissue,  from  increased  vascularity.  The  consistence  of 
the  growth  is  thus  much  changed,  and  from  its  softness  its  true  nature 
may  be  mistaken. 

After  parturition,  an  involution  of  the  muscular  elements  of  the 
tumour  occurs  simultaneously  with  that  of  the  uterus  itself ;  and  this  may 
be  so  marked  that  x)ositive  diminution  or  even  total  disappearance  of  the 
tumour  may  occur.  This  happy  result  is  probably  attained  by  firm 
uterine  contraction  impairing  the  blood-supply  to  the  growth,  and  caiis- 
ing  a  degeneration  of  the  muscle  fibres  analogous  to  that  which  occurs 
in  normal  puerperal  involution. 

Such  a  favourable  termination  is  unfortunately  by  no  means  the  rule  ; 
indeed,  from  my  own  observations,  a  permanent  enlargement  of  the 
tumour  is  the  more  common  consequence.     In  some  cases  this  is  more 

2q 


594  SYSTEM  OF  GYNAECOLOGY 

evident  than  in  others,  and  is  due  to  the  extrusion  of  the  growth  from  the 
uterine  wall,  by  contraction  of  the  oi'gan ;  but  in  many  instances  I  have 
carefully  noted  a  permanent  increase  after  pregnancy,  a  result  which 
probably  accounts  for  the  frequency  of  subsequent  sterility  (see  p.  563). 
Puerperal  uterine  contractions  often  cause  expulsion  of  submucous 
growths ;  this  I  have  seen  twice  within  two  months  of  the  confinement,  the 
expulsion  in  each  case  being  associated  with  alarming  hemorrhage.  Sub- 
mucous tumours  are  also  liable,  from  the  contraction  of  the  uterus  cutting 
off  their  blood-supply,  to  become  gangrenous,  and  hence  to  be  a  source 
of  septic  infection.  This  result  may  also  occur  in  subserous  tumours. 
From  the  serous  infiltration  present  during  pregnancy  the  tumour  may 
continue  to  grow  rapidly  after  delivery,  from  increased  connective  tissue 
proliferation  and  other  secondary  changes. 

True  suppuration  may  be  met  with  in  subserous  tumours  as  a  result 
of  parturition;  this  has  been  shown  by  Speigelberg  to  be  due  to  the 
passage  of  organisms  from  the  uterus  through  the  lymph  spaces.  These 
tumours  may  also  slough  from  bruising  during  labour,  and  may  thus 
give  rise  to  fatal  peritonitis. 

Gangrene  and  sloughing  of  a  submucous  polypus  is  described  by 
Charrier  to  have  occurred  during  pregnancy;  the  patient  recovered, 
though  birth  of  the  foetus  took  place  before  the  removal  of  the  septic 
mass. 

Submucous  polypi  have  frequently  been  described  as  presenting  in 
front  of  the  foetus  during  labour,  and  in  several  instances  have  been 
mistaken  for  the  foetal  head  and  delivered  by  forceps  (21). 

The  diagnosis  of  j)regnancy  loith  fibromyoma  is  usually  simple,  though 
at  times  great  difficulty  may  be  experienced. 

The  presence  of  ameuorrhoea,  coincidently  with  an  excessive  enlarge- 
ment of  the  uterus  and  attached  tumour,  is  at  all  times  suspicious  and 
almost  characteristic.  Occasionally,  however,  menstruation  may  continue 
for  some  months  in  spite  of  gestation,  and  here  by  palpation  alone  can 
the  true  condition  be  ascertained. 

Large  interstitial  tumours  when  associated  with  pregnancy  may,  from 
the  regular  contour  of  the  rapidly  enlarging  tumour,  closely  simulate  a 
hydatidiniform  degeneration  of  the  chorion  (9)  or  a  rapidly  growing 
cystic  myxo-sarcoma. 

In  like  manner  an  intraligamentary  growth  may  resemble  an  extra- 
uterine gestation  so  closely,  that  absolute  certainty  of  diagnosis  is  im- 
possil^le.  Simpson  describes  such  a  case  (58).  If,  however,  in  these  cases 
the  uterus  itself  be  definable  from  the  intraligamentary  growth,  its  size 
will  Ije  of  great  value  in  distinguishing  it  from  an  extra-uterine  gestation ; 
as  in  the  latter  the  uterus,  though  enlarged,  never  corresponds  with  the 
size  of  a  normal  intra-uterine  pregnancy. 

From  the  difficulties  which  may  be  due  to  the  tumour  masking  the 
signs  of  pregnancy,  it  is  well  in  all  cases  of  rapidly  growing  fibroids  to 
remember  the  possibility  of  its  concurrence,  as  by  this  caution  many 
serious  and  even  fatal  errors  may  be  avoided. 


BENIGN   GROWTHS    OF   THE    UTERUS  595 

The,  treatment  to  he  adopted  ivhere  pregnancy  is  complicated  hy  fihro- 
myoma  must  vary  according  to  the  existing  conditions  in  each  individ- 
ual case.  Unless  urgent  symptoms  demand  active  measures  interference 
is  uncalled  for. 

When  the  growths  are  small,  pregnancy  is  but  seldom  affected  by 
their  presence ;  and  even  large  tumours  may  but  slightly  interfere  with 
its  normal  completion.  The  methods  by  which  nature  may  overcome 
difficulties  apparently  insuperable  is  certainly  surprising.  Many  cases 
are  on  record  of  primarily  incarcerated  growths  which  have  grown  up- 
wards into  the  abdomen  after  gestation  was  far  advanced ;  indeed,  this 
may  take  place  even  during  labour,  as  the  result  of  retraction. 

When  from  pressure  or  other  causes  interference  is  demanded,  the 
position  and  character  of  the  growth  must  necessarily  define  the  method 
of  treatment.  When  low  in  the  uterus  and  remaining  pelvic,  it  may  give 
rise  to  symptoms  of  gravid  retroversion ;  or,  as  in  a  case  of  my  own,  such 
symptoms  may  be  induced  by  a  large  tumour  of  the  anterior  wall  causing 
the  gravid  uterus  itself  to  be  retroposed  and  incarcerated.  In  these 
cases,  even  if  pressure  symptoms  be  absent  which  they  seldom  are, 
attempts  at  reposition  are  demanded,  as  the  tumour  must  form  an  unsur- 
mountable  barrier  to  delivery. 

If  no  symptoms  of  pressure  be  present,  though  incarceration  exist 
in  spite  of  attempts  at  reposition,  it  is  well  to  allow  pregnancy  to  pro- 
ceed without  interference,  as  the  tumour  in  the  later  months,  or  even 
during  labour,  may  be  drawn  out  of  the  pelvis  and  in  no  way  interfere 
with  delivery.  Should  it  still,  however,  remain  fixed,  and  thus  entirely 
block  the  passage  of  the  child,  laparotomy  is  the  only  resource.  The 
choice  of  operation  to  be  adopted  must  vary  Avith  the  situation;  but 
complete  hysterectomy  would  certainly  appear  to  be  preferable  to  either 
simple  Caesarean  section  or  Porro's  operation.  The  mortality  from 
Caesarean  section  is  stated  by  Sanger  to  be  83-7  per  cent.  The  induction 
of  abortion  Avhen  the  tumour  is  placed  low  in  the  uterus  is  rendered 
difficult  and  dangerous  by  the  want  of  dilatability  of  the  lower  uterine 
segment  and  cervix,  which  may  render  it  impossible  to  introduce  the 
finger  for  removal  of  the  secundines.  Should  the  tumour  be  intra- 
vaginal,  its  removal  can  at  any  time  be  performed  without  inducing 
labour. 

Large  abdominal  fibroids  with  pregnancy,  which  give  rise  to  urgent 
symptoms,  may  be  treated  either  by  induction  of  labour  or  abdominal 
section.  The  former  operation,  on  account  of  its  minor  severity',  has 
been  strongly  advocated  by  a  large  number  of  writers,  but  has  been 
equally  strongly  condemned  by  others,  who  base  their  arguments  partly 
on  the  high  mortality  after  even  spontaneous  abortion  —  which  has  been 
stated  by  Lefour  to  be  about  35  per  cent  —  and  partly  on  the  fact  that 
the  groAvth  remains  untreated. 

The  treatment  by  laparotomy  at  the  hands  of  Schroeder  (56)  and 
others  has  been  doubtless  most  satisfactory,  but  at  the  same  time  it 
shows  the  enormous  fatality  in  all  of  about  48  per  cent. 


596  SYSTEM  OF  GYNAECOLOGY 

The  details  of  the  operation  necessarily  vary  "with  the  position  and 
size  of  the  tumour.  If  pedunculated,  the  tumour  may  be  removed  by 
myomectomy,  and  the  pregnancy  continue ;  a  successful  result  is  thus 
frequently  obtained.  If  sessile  or  interstitial,  the  site  or  size  of  the 
growth  must  govern  the  method  of  operation,  yet  even  in  these  cases 
myomectomy  has  been  performed  without  interfering  with  the  progress 
of  gestation,  as  shown  by  Leopold  (41).  He  further  states  that  in 
thirt3'-one  cases  of  myomectomy  during  pregnancy  for  pedunculated  or 
sessile  tumours  seven  mothers  died,  twenty-one  were  operated  on  betAveen 
the  fourth  and  sixth  month,  and  seventeen  carried  to  full  time. 

The  Porro-Caesarean  operation,  or  the  entire  removal  of  the  uterus, 
are  the  methods  chiefly  followed.  A  successful  case  of  the  latter  has 
been  described  by  Jessett.  Ordinary  Caesarean  section,  on  account  of 
its  excessive  mortality  already  cited,  should  not  be  performed,  not  even 
in  the  few  cases  which  may  seem  suitable  for  its  adoption. 

In  general,  therefore,  the  magnitude  of  these  operations  and  their  far 
from  uniform  success,  would  incline  us  to  the  less  heroic  measure  of  the 
induction  of  abortion,  if  urgent  symptoms  should  arise  from  large  abdo- 
minal fibroids  complicating  pregnancy.  But  each  individual  case  must 
be  treated  on  its  own  merits,  the  urgency  of  the  symptoms  in  some  cases 
absolutely  demanding  immediate  surgical  interference.  When,  however, 
symptoms  are  not  so  urgent  as  to  require  such  energetic  measures, 
personal  experience  has  shown  that  abortion  may  be  induced  with  most 
happy  results,  and  the  future  treatment  of  the  tumour  can  be  under- 
taken with  decidedly  less  risk  at  a  subsequent  period. 

Treatment  of  fibkomyoma  may  be  divided  into  Medical,  Electrical, 
and  Surgical. 

The  medical  treatment  is  chiefly  symptomatic,  although  the  entire  dis- 
appearance of  growths  has  been  attributed  in  some  instances  to  its  means. 
Many  drugs  have  been  recommended  —  such  as  mercury,  iodides,  and 
liq.  calcis  chloridi  —  which  have  been  supposed  to  exert  a  direct  absorp- 
tive effect  on  the  tumour,  and  probably  not  without  some  reason. 
Sodium  chloride  mineral  waters  have  an  undoubted  effect  in  this  direc- 
tion. Since  the  rapid  advancement  of  surgery  in  gynaecology,  however, 
such  uncertain  methods  have  practically  ceased  to  command  attention, 
and  treatment  by  drugs  is  now  almost  entirely  confined  to  purely  symp- 
tomatic uses. 

As  in  the  majority  of  cases  haemorrhage  is  the  urgent  symptom,  and 
as  it  is  one  which  more  readily  lends  itself  to  medicinal  antidotes,  it  is 
needless  to  say  that  the  drugs  used  to  control  it  are  many.  Sulphuric  and 
gallic  acids,  turpentine,  cannabis  indica,  and  many  others,  have  had  their 
day  ;  but  there  is  none  which  has  in  any  way  a))proached  the  value  of 
ergot  of  rye  which,  so  far  as  present  medifial  treatment  is  concerned, 
holds  the  field.  Many  writers  strongly  urge  that  by  its  use  the  develop- 
ment of  the  tumour  is  prevented,  and  its  size  actually  reduced.  There  can 
be  but  little  doubt  that  such  a  result  is  occasionally  met  with ;  although 
usually  not  until  after  many  months  or  even  years  of  active  and  regular 


BENIGN  GROWTHS   OF   THE    UTERUS  597 

employment.  The  action  of  ergot  appears  to  be  twofold :  firstly,  by 
causing  contractions  of  the  uterus,  it  tends  to  expel  the  tumour  from  its 
wall,  and  at  the  same  time  retards  its  circulation  by  direct  pressure ; 
secondly,  by  its  well-known  direct  contractile  action  on  the  blood-vessels, 
it  materially  interferes  with  the  nutrition  of  the  growth.  Though  ergot 
seems  but  seldom  to  exert  a  curative  effect  upon  the  growth  and  develop- 
ment of  the  tumour,  it  is  of  great  value  in  reducing  the  large  amount  of 
haemorrhage  associated  with  many  of  them,  and  as  a  uterine  haemostatic 
it  has  had,  and  still  occupies  a  high  position ;  though  the  more  decided 
results  derived  from  the  scientific  use  of  the  galvanic  current  are  now 
rapidly  superseding  this  form  of  treatment.  As  directed  by  Hildebrandt, 
who  first  introduced  it, ergot  is  best  employed  by  hypodermic  injection; 
and  for  this  purpose  the  solution  recommended  by  Prof.  A.  R.  Simpson  is 
very  suitable,  namely,  I^  Ergotine  3ij.,  Chloral  hyd.  3iv.,  Aq.  dist.  3vj. 
Twelve  drops  of  the  above  contain  3  grs.  of  ergotine,  which  is  an  ordinary 
dose.  The  chloral  is  merely  added  as  a  preservative.  Care  must  be 
taken  to  inject  the  solution  deeply  into  some  fleshy  part,  such  as  the 
buttock,  so  as  to  avoid  abscess  formation.  The  injections  are  to  be 
made  twice  weekly  as  a  rule,  but  every  second  day  during  the  menstrual 
period ;  in  this  manner  its  use  must  be  continued  for  months  if  any 
change  in  the  growth  is  to  be  anticipated.  The  patient  may  be  taught  to 
inject  herself.  The  drug  may  be  given  by  the  mouth,  or  by  suppository ; 
but  it  seems  thus  to  have  a  less  decided  effect. 

Of  late  the  fluid  extract  of  hydrastis  canadensis,  in  20  to  30  minim 
doses,  has  been  employed  as  a  uterine  haemostatic  in  bleeding  fibroids, 
and  its  use  has  met  with  much  favour.  From  the  difficulty  in  procuring 
the  drug  in  a  fresh  state,  however,  treatment  by  this  means  has  been 
too  limited  to  form  reliable  results. 

Electrical  Treatment. — The  treatment  of  fibromj'oma  by  electricity, 
though  by  no  means  a  new  method,  had  not  been  undertaken  in  a 
thoroughly  scientific  manner  until  comparatively  recent  years.  Routli  in 
his  interesting  and  able  work  (54)  speaks  of  it  in  1853  as  a  comparatively 
new  method,  and  describes  a  case  in  which  he  got  a  most  favourable 
result  by  passing  daily  through  the  tumour  a  current  of  high  intensity 
for  two  hours  at  a  sitting.  This  proceeding  was  discontinued  after  about 
fifteen  applications,  as  the  patient  suffered  from  ulceration  of  the  parts 
at  the  sites  of  the  electrodes,  which  were  placed  on  the  back  and  cervix 
respectively. 

After  that  time  it  was  used  only  in  an  occasional  and  haphazard 
fashion  until  Apostoli  in  1886  again  called  attention  to  its  value,  and 
brought  the  subject  forward  on  a  more  exact  and  scientific  basis ; 
Apostoli's  method  evoked  much  interest,  and  was  the  source  of  endless 
discussion  of  a  most  animated  and  even  bitter  kind.  Now,  however, 
that  these  useless  polemics  have  abated,  and  the  treatment  can  be  seen 
in  an  unprejudiced  light,  its  high  value  becomes  apparent. 

Apostoli's  method  is  fully  described  in  the  article  on  the  "  Electrical 
Treatment  of  Diseases  of  Women.  " 


598  SVSTE.V   OF  GYNECOLOGY 

The  action  of  the  current  thus  administered  is  said  to  be  twofold  — 
local  and  interpolar. 

Be  this  as  it  may  —  chemical,  vaso-motor,  or  otherwise  —  there  is  no 
gainsaying  the  large  array  of  successful  cases  cited  by  Apostoli,  Keith, 
Milne  Murray,  and  many  others,  where  the  current  acted  beneficially, 
—  first  as  a  haemostatic,  secondly,  by  arresting  the  growth  of  the  tumour, 
and,  thirdly,  in  many  instances  actually  causing  permanent  diminution  in 
the  size  of  the  tumour.  With  ordinary  care  the  treatment  can  be  carried 
out  without  risk  and  with  little  inconvenience. 

As  a  haemostatic  it  will  seldom  be  found  to  fail  if  the  tumour  be 
smaller  than  a  six  months'  pregnancy.  Larger  tumours,  however,  do  not 
seem  to  be  so  rapidly  benefited,  although  they  are  by  no  means  beyond 
the  scope  of  beneficial  influence. 

Pressure  symptoms,  as  a  rule,  are  relieved  greatly  and  promptly,  while 
the  feeling  of  "well-being"  evinced  by  the  patient  is  frequently  rapidly 
developed,  and  forms  one  of  the  most  satisfactory  benefits  of  the 
treatment.  It  has  been  averred  that  the  symptoms  of  pressure,  of 
haemorrhage,  etc.,  are  merely  temporarily  benefited,  and  recur  as  soon  as 
the  use  of  the  electricity  ceases.  That  they  do  return  in  some  cases  is 
true,  as  in  some  cases  removal  of  the  appendages  fails  to  stop  menstrua- 
tion ;  but  in  the  great  majority  of  instances  a  permanent  arrest  of 
bleeding  and  a  diminution  in  the  size  of  the  tumour  is  the  result.  Out 
of  twenty-five  cases  in  which  I  arrested  excessive  haemorrhage  more  than 
two  years  ago,  in  only  four  has  it  returned,  and  then  Avas  stopped  again 
by  similar  methods  (30). 

The  arrest  in  development  and  permanent  diminution  in  the  size  of 
the  tumour  is  equally  striking.  Apostoli  computes  it  to  occur  in  95 
per  cent  of  cases.  In  submucous  tumours  the  tonic  uterine  contractions 
induced  by  the  current  tend  in  many  instances  to  cause  them  rapidly  to 
become  pedunculated,  and  further  to  expel  them  as  polypi.  This  I  have 
noticed  in  eight  of  my  last  fifty  cases. 

From  its  great  success  this  method  of  electricity  should,  as  a 
conservative  method  of  treatment,  be  tried  in  all  cases  before  the  larger 
and  more  dangerous  operations  are  attempted.  Should  it  fail  (as 
undoubtedly  it  sometimes  does)  the  chances  of  successful  operation,  so 
far  as  my  experience  shows,  are  in  no  way  diminished,  though  the 
contrary  is  averred  by  some  surgical  opponents  of  the  method. 

When  from  incarceration  of  the  tumour  in  the  pelvis,  or  from 
any  other  causes,  it  may  be  found  impossible  to  introduce  the  intra- 
uterine electrode,  it  becomes  necessary  to  puncture  the  tumour  through 
the  vaginal  wall. 

It  is  probable  that  after  puncture  adhesions  will  be  set  up,  and  thus 
complicate  subsequent  operation:  this  result  should  always  be  remem- 
bered, before  this  method  of  .treatment  is  adopted,  as  it  forms  a  slight 
foundation  upon  which  antagonists  of  the  electrical  treatment  of  fibroids 
generally  are  but  too  eager  to  build  their  arguments. 

Fortunately  the  cases  where  puncture  is  necessary  are  rare,  as  in  the 


BENIGN  GROWTHS   OF   THE    UTERUS  599 

majority  of  instances  the  cervix  is  freely  accessible  to  the  introduction 
of  the  sound- 
Surgical  Treatment. — This  may  be  either  symptomatic  or  radical, 
vaginal  or  abdominal. 

The  symptomatic  vaginal  methods  of  treatment  are  naturally  directed 
against  the  two  urgent  conditions  of  pressure  and  haemorrhage. 

Treatment  of  Pressure  Symptoms.  —  The  feeling  of  down-bearing,  and 
the  accompanying  vesical  symptoms,  so  frequently  complained  of  as  due 
to  the  simple  increased  weight  of  the  uterus,  may  be  much  benefited  by 
the  introduction  of  an  accurately  fitting  ring  pessary. 

The  extremely  distressing  pressure  symptoms  of  fibroids  located  in 
the  true  pelvis  may,  if  the  growth  be  subserous  and  incarcerated,  be 
generally  removed  by  elevating  the  tumour  above  the  brim  of  the  pelvis, 
and  maintaining  it  in  this  position  by  a  simple  Hodge  or  ring  pessary. 
This  is,  of  course,  applicable  only  to  freely  movable  growths  such  as 
pedunculated  subserous  tumours  in  the  fundus  of  a  retroverted  or  flexed 
uterus.  When  arising  from  the  supravaginal  cervix  or  lower  part  af 
the  uterine  body  such  manipulation  is  impossible,  the  tumour  being 
absolutely  fixed  in  the  pelvis. 

The  elevation  of  the  tumour  is  most  easily  performed  with  the 
patient  in  the  Sims'  or  genu-pectoral  position ;  steady  upward  pressure 
by  the  fingers  is  to  be  made  through  the  vagina,  or  rectum,  in  a  manner 
similar  to  that  recommended  for  the  reposition  of  a  gravid  retroflexion 
of  the  uterus.  Should  any  difficulty  be  met  with  the  patient  should  be 
anaesthetised,  as  thus,  by  the  relaxation  of  parts,  resistance  is  frequently 
diminished  in  a  surprising  manner. 

Treatment  of  Hcemorrhage.  —  The  mechanical  methods  for  the  arrest  of 
haemorrhage  are  manifold,  and  perhaps  the  most  simple  is  intra-uterine 
injection  or  swabbing.  The  substances  which  have  been  used  for  this 
purpose  include  almost  all  known  styptics ;  but  that  which  seems  to 
have  given  the  most  satisfactory  results  is  undoubtedly  iodine.  Dr. 
Savage  was  the  first  to  recommend  this  drug,  and  he  preferred  the 
injection  of  1  or  2  drachms  of  the  strong  undiluted  Edinburgh  tincture. 
He  Avas  careful,  however,  to  observe  that,  before  injection,  dilatation  of 
the  uterus  must  be  obtained  which,  by  allowing  of  the  free  egress  of 
the  injected  fluid,  prevents  the  intense  pain  and  occasional  subsequent 
attacks  of  peritonitis  previously  met  with  after  this  method  of  treatment. 
Swabbing  the  interior  of  the  uterus  with  a  dressed  uterine  sound,  pre- 
viously dipped  in  the  tincture  of  iodine,  is  to  be  preferred  to  the  intra- 
uterine injections ;  it  is  more  easily  performed,  and  is  equally  efticacious. 

In  preference  to  the  use  of  the  strong  tincture,  I  have  \;sod  with  al- 
most unfailing  success  a  weak  solution  of  the  same  tincture  (3ij .  to  5  xvj .  of 
water),  and,  with  a  Fritsch  or  Ffozeman's  catheter  introduced  to  the  fundus 
uteri,  allowed  the  whole  quantity  slowly  to  pass  through  the  uterus. 
This  should  be  performed  about  the  second  or  third  day  of  the  period, 
and  so  far  experience  has  shown  that  it  can  be  thoroughly  relied  upon. 
Previous  dilatation  is  seldom  necessary  to  allow  of  the  introduction  of 


6oo  SYSTEM   OF  GYNECOLOGY 


the  catheter,  as  diiring  the  menstrual  period  marked  softening  of  the 
cervix  and  even  dilatation  of  the  os  are  usually  met  with. 

Intra-uterine  douching  with  hot  water  is  a  most  valuable  method  of 
rapidly  arresting  uterine  haemorrhage.  The  water  should  be  used  at  a 
heat  exceeding  110°  F.,  as  below  this  temperature  it  only  aggravates  the 
condition.  Simple  vaginal  syringing  with  water  at  the  same  tempera- 
ture frequently  has  an  immediate  haemostatic  effect,  by  causing  strong 
uterine  contraction ;  but  this  cannot  be  depended  upon.  This  action  of 
hot  water  has  been  shown  by  Dr.  Murray  to  be  due  to  the  contractile 
effect  upon  imstriped  muscle ;  thus  the  uterus  itself,  and  the  walls  of 
the  blood-vessels,  are  thrown  into  a  prolonged  tonic  spasm  without  subse- 
qiient  reaction. 

Plugqing.  —  This  may  be  either  vaginal  or  uterine,  and  is  demanded 
when  the  haemorrhage  is  so  severe  as  to  threaten  life.  Intra-uterine 
plugging  by  means  of  tupelo  tents  is  the  best  method,  as  not  only  is  direct 
pressure  thus  frequently  brought  to  bear  on  the  actual  bleeding  surface, 
but  the  resultin:^  dilatation  may  assist  in  a  marked  degree  in  arresting 
subsequent  bleeding ;  after  removal  of  the  tents,  also,  direct  intra-uterine 
exploration  can  be  made,  and  any  subsequent  operation  performed  which 
may  seem  advisable.  Emmet  recommends  plugging  the  uterus  Avith  a 
tampon  of  cotton  soaked  in  a  solution  of  alum ;  this  he  introduces  into 
the  uterus  in  the  form  of  a  strip,  an  end  being  left  hanging  from  the 
cervix  for  subsequent  removal,  should  the  uterus  fail  to  expel  it  by  in- 
duced contraction  (19). 

Dilatation  of  the  cervix,  either  by  bougies  and  tents  or  by  free  incis- 
ion, has  been  long  known  in  some  cases  to  have  a  marked  effect  in 
stopping  the  hcemorrhage  from  fibroids  ;  and  at  one  time  it  was  a  very 
generally  adopted  method  of  treatment.  It  is  very  useful  in  relieving 
the  dysmenorrhoea  so  often  met  with  in  submucous  tumours.  The  haemo- 
static action  is  ascribed  by  Simpson,  Nelaton,  and  others  as  due  to  dilata- 
tion allowing  the  uterus  to  retract  and  contract  firmly  upon  the  contained 
tumour,  and  thus  by  compression  of  the  vessels  to  prevent  haemorrhage. 

Incision  of  the  capsule  of  the  tumour,  although  followed  immediately 
by  a  temporary  excess  of  bleeding,  subsequently  diminishes  the  haemor- 
rhage to  a  great  extent.  This  action  is  probably  due  to  the  relief  of 
tension  in  the  capsule,  which  permits  of  the  retraction  of  the  lacerated 
sinuses  from  whence  the  bleeding  arises,  and  at  the  same  time  mitigates 
the  congestion  which  is  present.  Not  only  has  incision  a  hemostatic 
effect,  but  it  has  been  recommended  as  a  curative  method,  in  order  that, 
as  the  circulation  of  the  tumour  is  impaired  by  the  destruction  of  the 
capsule,  the  gi-owth  may  undergo  retrograde  changes,  and  slough ;  as  in 
some  cases  of  polypus  in  which  from  pressure  or  other  causes  the  nutrition 
is  likewise  interfered  with.  This  method  of  treatment  cannot,  however, 
be  too  strongly  condemned ;  as  fatal  re.sults  commonly  occur,  in  conse- 
quence of  the  absorption  of  septic  organisms  from  the  gangrenous  tumour. 

Curettage  of  the  uterine  cavity  is  a  procedure  much  practised  by 
many  gynaecologists.     In  cases  of  the  small  interstitial  growths,  which 


BENIGN  GROWTHS   OF  THE    UTERUS  601 

do  not  change  the  regular  shape  of  the  uterine  canal,  the  operation  may 
be  practised  with  much  temporary  benefit  as  regards  the  menorrhagia; 
but  in  the  vast  majority  of  cases,  which  are  projecting  submucous 
growths,  the  use  of  the  curette  is  of  but  little  value,  from  the  impossi- 
bility of  removing  the  entire  mucosa,  and  specially  that  portion  of  it 
which  actually  covers  the  growth,  and  which  is  the  most  fertile  source 
of  the  haemorrhage.  At  the  saine  time  the  operation  is  by  no  means 
devoid  of  risk ;  as  occasionally,  froju  severe  laceration  and  destruction 
of  the  capsule,  subsequent  death  and  gangrene  of  the  tumour  follow. 
In  one  case  I  have  seen  fatal  consequences  from  this  method  of  treat- 
ment, due  to  septicaemia  from  gangrene  of  the  tumour. 

Removed  of  the  Uterine  Appeivkufes.  —  As  a  curative  method  of  treat- 
ment for  the  bleeding  from  uterine  myoma,  this  operation  was  first  per- 
formed by  Lawson  Tait  in  1872 ;  since  that  time  increased  experience 
has  proved  it  to  be  one  of  the  greatest  advances  in  gynaecological  surgery. 
About  the  same  time  Battey  of  Georgia  performed  the  operation  of  re- 
moval of  the  ovaries  for  dysmenorrhoia ;  but  to  Tait  must  the  credit  be 
given  of  associating  the  operation  with  the  cure  of  fibroid  tumours.  The 
actual  operation  also  differs  materially  in  the  fact  that  Tait,  while  remov- 
ing the  ovaries,  at  the  same  time  removes  as  much  as  possible  of  the 
Fallopian  tube ;  by  this  means,  he  avers,  the  beneficial  effect  of  the 
operation  is  much  increased,  through  the  consequent  destruction  of 
the  nervous  supply  to  the  endometrium,  which  is  chiefly  centred  in  a 
large  nerve  trunk  which  enters  the  uterus  just  underneath  the  angle  of 
attachment  of  the  Fallopian  tube. 

The  statistics  of  Tait  are  indeed  striking,  and  those  of  other  eminent 
operators  are  worth  perusal.  Thus,  Tait  shows  that  of  the  first  272 
cases  in  which  he  had  operated  in  this  manner  for  uterine  fibromyoma, 
twelve  succumbed  from  the  operation  ;  a  mortality  of  44  per  cent.  He 
further  records,  that  of  fifty  cases  folloAved  for  six  years  after  the  opera- 
tion, in  seventeen  the  tumour  had  entirely  disappeared ;  and  in  fourteen 
had  become  so  diminished  as  to  be  harmless  :  forty-one  of  the  fifty  were 
in  perfect  health.  From  what  has  been  stated,  it  will  be  seen  that  the 
operation  not  only  has  the  effect  of  arresting  the  luemorrhage  and  the 
growth  of  the  tumour,  but  in  the  majority  of  cases  it  actually  causes 
diminution  in  its  size ;  in  many  instances,  indeed,  total  atrophy  and 
disappearance  of  the  growth  have  been  noted. 

Cases  of  failure  are  to  be  accounted  for  in  two  ways:  firstly,  inability 
or  neglect  to  remove  the  entire  Fallopian  tube  with  its  surrounding 
nerves ;  and,  secondly,  the  nature  of  the  growth.  From  the  size  of  the 
tumour,  or  from  the  direction  of  its  growth,  the  layers  of  the  broad 
ligament  may  become  so  split  that  removal  of  the  entire  appendages 
is  impossible ;  the  operation  is  then  valueless,  both  as  regards  the  arrest 
of  haemorrhage  and  increase  in  size;  to  this,  probably,  the  majority  of 
failures  in  arresting  menorrhagia  is  to  be  credited. 

It  would  appear  that  in  the  majority  of  cases  the  growth  of  oedema- 
tous  tumours  is  not  arrested. 


6o2  SYSTEM   OF  GYNyECOLOGY 

In  cases  of  prominent  submncous  tumours  the  haemorrhage  is  fre- 
quently aggravated  after  the  operation ;  but  expulsion  of  the  tumour 
■within  a  few  months  may  follow.  Should  haemorrhage  continue,  there- 
fore, after  an  apparently  complete  operation,  the  cavity  of  the  uterus 
should  be  carefull}^  explored  again  by  the  finger,  so  that  this  source  of 
trouble,  if  present,  may  at  once  be  removed. 

From  the  low  mortality  and,  as  statistics  further  show,  the  excellent 
results  accruing  from  its  adoption,  this  operation  cannot  be  too  highly 
commended  in  a  certain  proportion  of  cases.  The  discrimination  of 
suitable  cases  for  its  performance  cannot  be  fixed  by  definite  rules,  and 
this  must  be  determined  by  the  medical  attendant.  On  the  one  hand,  it 
is  not  to  be  hastily  adopted  before  less  severe  measures  have  been  tried ; 
and  on  the  other,  we  must  avoid  the  equally  blameworthy  procedure  of 
temporising  till  the  favourable  opportunity  has  passed. 

In  general,  it  may  be  said  that  the  operation  is  indicated  in  cases  of 
bleeding  and  growing  fibroids,  where  the  electrical  or  other  treatment  has 
been  tried  without  success ;  or  as  an  alternative  to  the  electrical  treat- 
ment, should  the  patient  so  decide  after  having  had  the  advantages  and 
disadvantages  of  both  fully  explained. 

The  wholesale  removal  of  uterine  appendages  for  fibroids,  without 
any  previous  attempts  at  treatment,  cannot  in  the  majority  of  cases  be 
too  strongly  condemned,  and  must  be  considered  not  only  unscientific, 
but  culpable.  Erom  the  ease  with  which  the  operation  can  be  performed, 
its  very  satisfactory  results,  and  the  exaggerated  credit  accruing  to  the 
operator ;  the  tendency  has  been  rampant,  and  unfortunately  still  exists, 
to  follow  this  line  of  treatment  in  all  cases  of  fibroid ;  the  majority  of 
which  are  amenable  to  treatment  by  methods  attended  with  less  risk 
and  with  no  mutilation.  Removal  of  the  appendages  should  never  be 
undertaken,  for  small  fibroids,  without  previous  dilation  and  exploration 
of  the  uterine  cavity,  as  small  submucous  polypi  may  be  the  sole  cause 
of  the  bleeding,  which  is  readily  cured  by  their  removal. 

O I  Id  rut  iom  for  Removal  of  the  Tumour.  —  (1)  Removal  of  pedunculated 
filn-oids.  The  methods  by  which  these  growths  are  to  be  removed  vary 
with  the  situation  and  extent  of  the  pedicle.  If  completely  intra-uterine, 
all  attempts  at  removal  must,  of  course,  be  preceded  by  dilatation  of  the 
cervix.  Should  no  previous  dilatation  of  the  cervix  exist,  this  is  to  be 
obtained  by  means  of  tents  or  Hegar's  dilators ;  but  in  the  majority  of 
cases,  where  the  intravaginal  cervix  and  os  uteri  externum  alone  are 
undilated,  free  bilateral  incision  by  scissors  up  to  the  reflexion  of  the 
vaginal  roof,  is  by  far  the  most  simple  and  efficacious  method. 

The  ease  with  wliieh  the  polypus  itself  can  be  removed  varies  accord- 
ing to  the  character  and  extent  of  the  pedicle.  Should  it  be  composed  but 
of  a  layer  of  mucous  membrane  —  as  met  with  in  the ''  free  "  variety  (see 
p.  576)  —  simple  torsion  of  the  growth  is  usually  sufficient;  but  should 
the  pedicle  be  thick  and  composed  of  uterine  muscle  (encapsulated  vari- 
ety), torsion  must  be  aided  by  cutting.  This  may  1)0  done  in  the  follow- 
ing inanner.    The  patient  is  placed  in  the  dorsal  position,  and  the  tumour 


BENIGN  GROWTHS   OF   THE    UTERUS  603 

exposed  by  means  of  specula  and  vaginal  retractors ;  the  growth  is  then 
seized  by  strong-toothed  forceps  and  slowly  rotated ;  with  blunt-pointed 
curved  scissors  the  pedicle  is  next  snipped  gradually  through,  rotation  of 
the  tumour  being  continued  as  far  as  possible  during  the  whole  time  of 
cutting  —  a  process  by  which  much  haemorrhage  is  frequently  avoided. 

Excessive  traction  on  the  tumour  is  to  be  avoided,  as  partial  inversion 
of  the  uterus  may  occur.  Indeed  the  inverted  portion  of  the  uterus 
has  been  mistaken  for  the  pedicle,  and  accordingly  snipped  through. 
In  all  cases,  therefore,  the  fundus  uteri  must  be  carefully  examined 
bimanually,  so  that  any  depression  of  inversion  may  be  recognised. 

Removal  of  polypi  by  means  of  the  serre-noeud,  chain  ecraseur,  and 
galvano-caustic  Avire,  are  still  favourite  methods  of  operation,  and  are  to 
be  recommended  as  safe  and  efficacious ;  but  as  they  have  no  advantages 
over  the  simple  cutting  method  described,  are  infinitely  more  tedious,  and 
involve  a  large  increase  in  the  already  large  armamentarium  of  the  gynae- 
cologist, they  are  rapidly  becoming  less  and  less  frequently  practised. 
The  haemorrhage,  after  removal  of  polypi  by  torsion  and  incision,  is 
usually  but  slight;  but  if  troublesome  is  readily  arrested  by  hot  water 
injection,  and  intra-uterine  plugging. 

In  cases  of  vaginal  polypi,  where  from  the  large  dimensions  of  the 
growth  access  to  the  pedicle  is  impossible,  reduction  in  the  size  of  the 
tumour  must  be  gained  by  the  removal  of  portions,  piecemeal,  until 
the  pedicle  is  reached.  In  some  of  these  cases  incision  of  the  tumour 
is  followed  by  a  considerable  loss  of  blood ;  but  this  can  usually  be  pre- 
vented by  strong  traction  and  torsion  of  the  growth,  aided  if  necessary 
by  a  running  loop  of  strong  cord  passed  round  its  base.  After  the 
pedicle  becomes  accessible,  traction  must  be  suspended  and  the  pedicle 
snipped  by  means  of  simple  torsion  and  scissors,  as  already  described. 
After  removal,  the  uterine  cavity  shoidd  be  thoroughly  washed  out  with 
an  antiseptic,  and  lightly  packed  for  twenty-four  hours  with  sterilised 
Berlin  wool  impregnated  with  iodoform.  The  packing  is  of  much  value 
in  rapidly  curing  the  endometritis  which  so  frequently  is  associated  with 
these  growths. 

Removal  of  Sessile  Tumours.  —  Simj^Je  Incision  of  the  Capsule.  —  This 
method  is  now  fortunately  almost  obsolete.  Its  advocates  contend  that  by 
its  adoption  removal  of  the  tumour  results  from  two  causes :  first,  from 
the  arrest  of  nutrition  of  the  tumour  by  interference  with  its  capsular 
circulation  ;  and,  secondly,  by  the  promotion  of  expulsion  of  the  growth 
from  its  capsular  surrounding  by  uterine  contraction.  By  this  means  it 
is  also  averred  that  the  natural  destruction  and  expulsion,  occasionally 
met  with,  are  closely  followed.  Greenhalgh  for  this  purpose  incised 
the  capsule  with  the  thermo-cautery ;  Baker-Brown,  after  free  incision 
of  the  capsule,  lacerated  the  growth  itself,  and  left  it  to  slough.  Other 
methods  of  hastening  the  destruction  of  the  tumour  after  capsular  in- 
cision, such  as  the  injection  of  perchloride  of  iron,  etc.,  have  also  been 
recommended. 

It  may  be  said  at  once,  however,  that  such  crude  and  unscientific 


6o4  SVSTEJl/  OF  GYNECOLOGY 

methods  should  never  be  permitted.  They  may  simuhite  a  natural 
process,  but  it  is  one  which  under  all  circumstances  is  fraught  with  much 
danger,  and  frequently  ends  fatally,  while,  further,  it  cannot  but  be 
apparent  that  the  oonditious  are  in  the  two  cases  essentially  different. 
In  nature's  action  we  have  to  deal  Avith  a  growth  which  is  practically 
cut  off  from  the  circulation,  lymphatic  and  other;  while  in  the  artificial 
method  we  are  suddenly  setting  up  suppuration  in  a  growth  freely  com- 
municating with  the  surrounding  tissues,  and  from  which  absorption  is 
but  too  ready  to  take  place.  It  will  thus  be  seen  that  if  dangerous 
under  natural  conditions  it  Avill  be  greatly  intensified  under  artificial 
conditions. 

The  other  vaginal  methods  of  surgical  interference  adopted  for  the 
removal  of  sessile  tumours  are:  — 

Simple  enucleation,  ligature  of  uterine  arteries,  simple  morcellation 
of  tumour,  simple  vaginal  hysterectomy,  vaginal  hysterectomy  by  mor- 
cellation. The  full  details  of  these  operations  will  be  found  in  other 
sections  of  this  work  devoted  to  surgical  methods. 

Eemoval  of  sessile  submucous  growth  per  vaginam  by  enucleation  was 
recommended  by  Velpeau,  Atlee,  Amussat,  and  others,  more  than  fifty 
years  ago;  but,  from  its  high  mortality,  it  rapidly  fell  into  disrepute. 
The  procedure  has,  however, within  the  last  few  years  been  renewed  with 
great  enthusiasm,  and,  fortunately,  on  improved  methods  and  with  a  know- 
ledge of  antiseptics,  has  been  practised  with  most  satisfactory  results. 

To  Emmet  is  probably  due  the  credit  of  the  revival  of  the  method  as, 
by  dogged  perseverance  throughout  the  last  thirty  years,  he  has  by  his 
traction  method  secured  results  which  at  once  elevate  the  operation  to 
a  position  worthy  of  adoption.  Undoubtedly  in  his  operation  is  to  be 
found  the  rudiments  of  "  morcellation  "  which  has  been  adopted  by  Pean 
for  the  removal  of  all  varieties  of  fibromyoma,  and  with  whose  name  it 
is  almost  entirely  identified. 

From  the  simple  removal  of  the  tumour  Pean  has  passed  to  the  more 
formidaljle  operation  of  vaginal  hysterectomy,  by  which  means  he  removes 
all  tumours  less  than  a  six  months'  pregnancy,  and  this  with  the  truly 
astounding  statistics  of  but  four  deaths  in  two  hundred  cases  (21).  In 
these  methods  he  has  been  worthily  followed  by  Kichelot  and  De  Ott, 
whose  comljined  statistics  show  143  cases  with  one  death. 

With  such  a  magnificent  array  of  successes,  one  must  admit  that  the 
operation  is  a  decided  advance  in  gynaecological  surgery,  and  heartily 
congratulate  the  operators  on  their  handiwork.  J>ut,  unfortunately, 
there  is  no  gainsaying  the  fact  that  this  success  has  stimulated  a  surgical 
fashion  in  this  direction  which  has  jjassed  far  beyond  the  limits  of  dis- 
cretion, and  cannot  be  too  strongly  denounced. 

In  no  country  has  the  operation  fever  l)ecome  more  acute  than  in 
America ;  and  when  one  reads  the  astounding  assertion,  that  all  fibroids 
should  be  ojierated  on  by  complete  hysterectomy  as  soon  as  discovered  (1), 
and  this  jjublished  by  an  operator  who  has  done  twenty  such  operations 
within  a  year,  it  is  surely  time  that  a  bold  front  should  be  opposed  to 


BENIGN  GROWTHS   OF   THE    UTERUS  605 

such  merciless  mutilation.  Like  almost  every  operation  in  surgery,  the 
operation  has  its  legitimate  place,  and  when  required  should  be  performed ; 
but  cases  needing  such  measures  form  but  a  small  minority  of  fibromyo- 
mas,  certainly  not  more  than  10  per  cent.  Simple  recovery  from  the 
operation  may  reach  97  per  cent,  but  in  many  cases  protracted  invalid- 
ism results.  Only  as  a  last  resort  is  it  warranted ;  the  less  energetic 
measures  of  electricity  and  removal  of  the  appendages,  in  the  majority 
of  cases,  are  amply  sufficient. 

The  abdominal  surgical  methods  of  removing  fibroids,  namely,  myo- 
mectomy and  hysterectomy,  are  fully  discussed  in  another  portion  of  the 
System.  They,  like  the  vaginal  methods  just  mentioned,  admirably  fill 
a  limited  function  in  the  treatment  of  these  tumours,  w^hich  is  not  only 
justifiable  but  necessary.  Such  measures  are  particularly  needed  in 
cases  of  growing  abdominal  tumours  larger  than  a  six  months'  pregnant 
uterus,  where  the  appendages  cannot  be  removed  entirely ;  and  also  in 
the  rapidly  growing  oedematous  cystic  growths,  Avhere  removal  of  the 
appendages  is  useless  and  therefore  unnecessary,  and  for  which  total 
removal  is  alone  of  avail. 

B.  Tumours  of  the  Mucous  Lining.  —  The  simple  mucous  growths 
of  the  uterus,  from  their  tendency  to  become  stalked  and  to  protrude 
through  the  os  externum  into  the  vagina,  are  generally  known  as 
"  mucous  polypi " ;  but  under  this  name  are  included  new  growths  of 
widely  different  character.  The  name  is  also  unhappy  in  so  far  as  it  is 
taken  to  represent  the  structure  rather  than  the  situation  of  the  neoplasm. 
Growing,  as  these  polypi  do,  from  the  mucosa,  they  are  the  result  of  a 
proliferation  of  the  glandular  or  connective  tissue  elements  alone  or  com- 
bined; and  include  therefore  adenomas,  fibro-adenomas,  and  fibromas. 

The  simple  adenoma  is  usually  met  wdth  in  the  cervix,  and  appears 
as  a  red,  soft,  smooth  growth,  varying  in  size  from  a  pea  to  a  w' alnut.  On 
section  it  shows  a  sponge-like  structure  due  to  the  dilated  glands,  which 
are  separated  from  one  another  by  thin  trabeculae  of  connective  tissue. 
The  gland  cavities,  visible  to  the  naked  eye,  are  filled  with  mucus;  and, 
microscopically,  they  may  be  seen  to  be  lined  with  epithelium,  varying 
from  cubical  to  elongated  cylindrical  forms.  The  tumour  is  covered  by 
epithelium  which  may  be  either  cubical  or  stratified  squamous.  The 
latter  form  I  have  found  covering  polypi  wdiich  sprung  from  at  least  a 
quarter  of  an  inch  within  the  canal  of  the  cervix,  and  protruded  into  the 
vagina  (30).  The  same  thing  has  also  been  demonstrated  by  Underbill 
and  Ackermann.  In  its  simplest  variety,  which  Semon  has  described  as 
a  papillary  outgrowth  from  the  vaginal  aspect  of  the  cervix,  this  form 
of  epithelial  covering  is  naturally  more  frequently  met  with. 

In  its  most  simple  form  this  variety  of  growth  is  represented  by  a 
simple  mucous  gland  which,  on  closure,  has  become  distended  with  mucus 
(Nabothian  follicle);  and  subsequently  so  protruded  from  the  surface 
that  it  has  become  pedunculated.  By  the  combination  of  a  series  of 
such  cysts,  with  proliferation  of  the  glandular  mucosa,  the  more  com- 
plex sponge-like  growth  is  formed. 


6o6  SYSTEM   OF  GYNAECOLOGY 

Usually,  witli  the  glandular  proliferation,  there  is  a  corresponding 
development  of  interglandular  connective  tissue :  this  is  generally  of  an 
extremely  cellular  character,  and  wanting  in  the  fibrous  elements.  The 
growth  in  this  instance  has  a  somewhat  firmer  consistence,  and  is  usually 
rough  on  its  surface,  so  that  it  resembles  a  ripe  strawberry.  These 
growths  may  be  sessile,  forming  protuberances  within  a  dilated  cervix ; 
and  it  is  probable  that  in  many  cases  they  owe  their  origin  to  cystic  ex- 
tension of  the  ncAV  glands  in  the  so-called  "  erosion "  of  the  cervix,  so 
frequently  met  with  in  cervical  inflammation. 

In  the  same  manner  an  inward  growth  of  the  new  glandular  structure 
into  the  cervical  tissues  with  subsequent  distension  of  the  glands  may 
arise,  which  is  well  known  as  "  follicular  hypertrophy  of  the  cervix." 

Localised  glandular  proliferation  of  the  mucosa  in  the  body  of  the 
uterus,  comparable  to  that  described  in  the  cervix,  and  giving  rise  to 
distinct  polypoidal  intra-uterine  growths,  has  been  described  by  Gusserow 
(27),  Schroeder  (57),  Duncan  (18),  and  others,  and  has  been  designated 
"adenoma  polyposa."  It  must,  however,  be  considered  as  of  rare 
occurrence. 

A  more  common  variety  of  intra-uterine  growth  is  the  fibro-adenoma, 
which  may  be  looked  upon,  primarily,  as  a  localised  hypertrophy  of  the 
normal  mucous  membrane.  Usually  in  these  cases  the  fibrous  tissue  pre- 
dominates, the  glands  tending  to  increase  rather  in  size  than  in  number, 
and  thus  to  form  canals  which  permeate  the  growth  in  all  directions ; 
this  variety  of  growth,  as  described  by  Underbill  and  others,  has  been 
called  "  channelled  polypus."  In  some  instances  these  growths  are  also 
found  growing  from  the  cervix.  They  may  grow  to  a  large  size ;  in  one 
example  described  by  myself  the  growth  weighed  21  ounces  (37).  When 
small  and  multiple  the  same  condition  has  unfortunately  been  described, 
by  Olshausen,  under  the  name  of  "  endometritis  f ungosa  polyposa  "  — 
a  name  at  once  misleading  and  scientifically  incorrect. 

These  neoplasms  would  appear  from  their  structure  to  owe  their 
origin  to  an  active  hypertrophy  of  the  fibrous  tissue  of  a  portion  of  the 
mucosa.  The  glands  situated  in  this  area,  however,  do  not  themselves 
actually  proliferate,  but  become  enormously  elongated  from  the  outward 
growth  of  their  surrounding  fibrous  stroma.  The  seat  of  active  growth 
is  seen  by  the  microscope  to  Ije  in  the  periphery  of  the  tumour,  im- 
mediately beneath  the  epithelium.  There  the  tissue  is  embryonic  and 
cellular,  while  towards  the  centre  it  is  fibrous  and  well  formed. 

By  dilatation  of  the  glands,  and  obstruction  to  the  escape  of  their 
secretion,  cysts  may  be  formed.  In  these  instances  the  growth  corre- 
sponds exactly  with  the  common  fibrocystic  tumours  of  the  mamma 
whicli,  among  many  other  names,  have  been  called  "fibroma  intra- 
canulaire  "  and  "  cystosarcoma  filirosum."  Like  the  mammary  tumours, 
they  are  essentially  benign  ;  though  in  a  certain  percentagf;  of  cases  they 
recur.  The  extremely  embryonic  and  cellular  chai-acter  of  the  periphery 
of  these  growths  might  certainly  lead  one  at  first  sight  to  classify  them  as 
sarcoma;  but  from  this  they  materially  differ  in  that  the  cells  do  not 


BENIGN  GROWTHS    OF  THE    UTERUS  607 

maintain  their  embryonic  character,  but  rapidly  develop  into  mature 
connective  tissue.  Moreover,  they  are  never  associated  with  metastases, 
or  infiltration  of  the  surrounding  lymphatics ;  and  it  would  appear  that 
when  recurrence  occurs,  it  is  due  not  to  a  local  malignancy  but  to 
hypertrophy  of  another  portion  of  the  mucosa. 

The  embryonic  blood-vessels  in  the  actively  growing  cellular  periph- 
ery, being  ill  supported  by  the  surrounding  stroma,  are  readily  ruptured ; 
such  is  probably  the  origin  of  the  violent  bleedings  which  form  so  char- 
acteristic a  clinical  feature  of  these  growths. 

Another  more  uncommon  variety  of  simple  polj^pus  found  growing 
from  the  uterine  mucosa  is  the  fibrous  papilloma.  This  is  a  purely  fibrous 
tumour  of  a  papillary  form,  covered  by  a  single  layer  of  epithelium. 
From  the  primary  growth  secondary  offshoots  are  developed,  each  carrying 
with  it  an  epithelial  covering  of  cubical  cells ;  thus  the  gross  appearance  of 
the  tumour  shows  a  rough,  irregular  surface  of  cauliflower-like  character. 
From  the  approximation  of  these  papillae,  the  interspaces  closely  resemble 
glands  permeating  the  substance  of  the  growth  and  opening  on  its  surface  ; 
but  on  microscopic  examination  their  true  structure  is  at  once  revealed. 
In  a  case  described  by  Rindfleisch,  small  cavities  lined  with  epithelium 
were  found  in  the  substance  of  the  polypus,  w^hich  he  ascribed  to  the 
coalescence  of  the  papillae  at  their  apices.  The  tissue  of  the  tumour 
proper  is  entirely  fibrous,  with  cells  in  all  stages  of  development ;  the 
centre  is  composed  of  well-formed  fibres,  while  towards  the  periphery  (as 
in  fibro-adenoma)  the  fibres  are  more  and  more  embryonic  :  thus  the  cen- 
trifugal development  of  the  neoplasm  is  demonstrated.  These  tumours  are 
frequently  described  as  "  cauliflower  papilloma  "  ;  but  as  this  name  is  more 
commonly  applied  to  malignant  epithelioma  of  like  appearance,  it  leads 
to  confusion  and  should  be  dropped.  Apart  altogether  from  the  nomen- 
clature, they  have  been  reckoned  as  closely  allied  to  epithelioma,  but 
microscopic  examination  and  clinical  observation  at  once  disprove  such  an 
affinity.  Isolated  cases,  as  those  quoted  by  Wagner,  may  occur  in  which 
a  simple  fibrous  papilloma  may  subsequently  develop  into  a  malignant 
epithelioma,  by  proliferation  of  its  epithelial  elements.  Such  an  event, 
however,  can  only  be  a  coincidence.  Such  a  transformation  is  far  more 
likely  to  occur  in  the  adenomatous  types,  where  large  numbers  of 
epithelial  cells  are  in  active  proliferation ;  it  is  probable  that  in  many 
instances  this  variety  of  growth  may  be  the  origin  of  it,  and  more 
especially  the  papillary  type  described  by  Semon  (alreadj-  mentioned), 
which  is  covered  by  many  layers  of  squamous  cells. 

From  what  has  been  shown  of  their  structure,  it  will  be  evident  that 
all  mucous  polypi  result  from  the  increased  growth  of  one  or  other  of 
the  normal  tissues  of  the  mucosa,  namely,  from  the  glandular  and  con- 
nective tissues.  They  will,  therefore,  present  an  indefinite  number  of 
varieties  of  structure,  entirely  dependent  upon  the  comparative  excess  of 
each ;  and  they  are  to  be  classed  accordingly.  At  the  hands  of  some 
authors  they  receive  but  little  attention,  and  even  by  others  are  dismissed 
as  mere  local  inflammatory  excrescences.    Doubtless  such  a  classification 


6o8  SYSTEM  OF  GYNECOLOGY 

may  be  simple  and  conTenient,  but  as  a  scientific  description  it  cannot  be 
too  strongly  condemned.  If  consistently  adopted,  uterine  fibromyoma 
must  be  looked  upon  as  localised  metritis,  and  ovarian  fibromyoma  as 
a  kind  of  ovaritis.  It  is  surely  strange  that  the  mucous  growths  of  the 
uterus  should  be  thus  summarily  dealt  with,  while  similar  conditions  of 
the  mamma,  nose,  and  intestines  are  described  as  definite  and  inde- 
pendent neoplasms. 

Sym-ptoms.  —  The  ever  present  symptoms  which  direct  the  attention  of 
patient  and  physician  to  mucous  polypi  are  leucorrhcea  and  haemorrhage. 
The  former  is  perhaps  the  more  characteristic,  and  sometimes  occurs  in 
almost  incredible  quantities,  associated  with  much  irritation  and  pruritus 
vulvae.  Its  character  varies  :  generally  it  is  clear,  watery,  and  odourless ; 
but  it  may  be  muco-purulent.  There  is  but  little  tendency  to  that  necrosis 
of  the  tissues  of  the  tumour  which  gives  the  characteristic  foetid  char- 
acter to  malignant  papillomas.  Haemorrhage  also  is  often  profuse,  and 
is  by  no  means  confined  to  the  menstrual  periods,  metrorrhagia  being 
particularly  frequent. 

The  source  of  bleeding  is  not  far  to  seek  when  it  is  remembered 
how  feebly  supported  are  the  numerous  embryonic  blood-vessels  in  the 
periphery  of  the  tumour.  At  the  same  time  the  menorrhagia  is  probably 
increased  by  the  irritation  set  up  by  the  tumour. 

Unlike  fibromyoma  they  may  occur  at  all  ages ;  and  this  feature 
forms  perhaps  the  most  interesting  practical  point  in  their  consideration. 
Occurring,  as  they  often  do,  late  in  life,  many  years  after  the  menopause, 
they  give  rise  to  the  alarming  symptom  of  post-climacteric  bleeding,  and 
form  the  large  majority  of  the  few  cases  in  which  this  symptom  is  not 
due  to  malignant  disease.  We  have  seen  that  they  may  occur  on  any 
portion  of  the  uterine  mucosa,  but  they  are  most  frequently  met  with  in 
the  cervical  canal.  Their  size  is  usually  less  than  that  of  a  walnut,  and 
they  may  assume  most  varied  shapes.  In  most  instances  they  are  smooth 
and  soft,  though  in  the  papillary  type  the  contrary  is  the  case.  As  has 
already  been  shown,  they  have  a  marked  tendency  to  recur  after  re- 
moval ;  Vjut  on  this  account  alone  they  cannot  be  called  malignant. 

When  palpable  their  diagnosis  is  as  a  rule  easy,  although  the  deter- 
mination of  simple  papillary  growth  from  papillary  epithelioma  can 
never  be  made  with  certainty  without  microscopic  examination. 

When  completely  intra-uterine  their  presence  is  frequently  not 
suspected,  and  patients  may  be  treated  for  long  periods  for  leucorrhoja 
and  uterine  haemorrhage,  with  slight  uterine  enlargement,  till  finally  on 
dilatation  of  the  cervix  their  presence  is  disclosed.  Severe  leucorrhoea 
and  uterine  haemorrhage  always  indicate  an  early  digital  exploration  of 
the  uterine  cavity. 

Intra-uterine  polypi,  and  particularly  the  variety  called ''  endometritis 
f  ungosa,"  may,  from  their  tendency  to  cause  post-climacteric  haemorrhage, 
be  difficult  to  distinguish  from  intra-uterine  cancer;  a  decision  can  be  made 
by  the  ini(;roscope  alone,  when  the  absence  of  active  ty])ical  epithelial 
jirolifcratioii   in  tli(!  glands  will  be  noted.     Malignant  disease  of  the 


BENIGN  GROWTHS   OF   THE    UTERUS  609 

uterine  body  is  commonly  associated  with  pain,  which  is  sehlom  present 
with  mucous  polypi,  unless  of  large  size. 

Although  in  their  recurrence  after  removal  they  still  more  closely 
simulate  malignant  disease,  they  never  give  rise  to  secondary  metastases, 
nor  are  associated  with  marked  cachexia. 

Treatment.  —  This  is  generally  to  be  summed  up  in  the  word  removal. 
When  small,  pedunculated,  and  projecting  through  the  cervix,  this  can 
easily  be  done  by  torsion  or  evulsion,  with  subsequent  cauterisation  of 
the  site  by  Pacquelin's  cautery.  This  latter  procedure  is  useful,  not 
only  in  arresting  the  hasmorrhage,  which  may  be  extremely  severe,  but 
also  in  so  destroying  the  base  that  recurrence  is  prevented. 

When  large,  their  removal  is  most  easily  effected  by  scissors,  as  in 
the  case  of  submucous  polypi  (see  p.  602).  The  stump  should,  however, 
if  possible,  be  thoroughly  cauterised  in  all  cases. 

Intra-uterine  polypi  necessarily  require  primary  cervical  dilatation. 

As  these  neoplasms  have  been  known  to  be  the  forerunners  of 
malignant  disease,  and  also  in  some  instances  to  recur  locally,  a  chance 
is  given  to  those  smitten  with  the  hysterectomy  furor  to  remove  the 
uterus.  Unless  actual  signs  of  malignancy  exist  such  a  procedure  is 
wholly  unwarrantable. 

I  have  more  than  once  been  called  upon  to  remove  successive  growths 
of  this  kind  from  the  same  patient,  and  I  can  recall  two  well-marked 
cases.  Five  years  ago,  for  the  fourth  time  in  eighteen  months,  I  re- 
moved from  a  patient  aged  fifty-nine,  still  alive  and  healthy,  a  large 
number  of  intra-uterine  adenomas,  which  had  given  rise  to  severe 
uterine  haemorrhage,  and  which  from  the  microscope  alone  I  knew  to 
be  of  simple  nature. 

In  the  other  case,  a  young  woman  of  twenty-three,  I  removed,  for 
the  last  time,  seven  years  ago,  and  three  times  within  two  years,  a 
simple  adenoma  of  the  cervix ;  since  then  she  has  had  perfect  health, 
has  married,  and  borne  four  children.  After  removal  of  intra-uterine 
adenomas,  cauterisation  of  the  interior  of  the  uterus  is  most  thoroughly 
and  easily  performed  by  means  of  fuming  nitric  acid,  followed  immedi- 
ately by  thorough  intra-uterine  irrigation. 

Another  variety  of  uterine  polypus,  but  not  strictly  anew  growth,  is 
the  uterine  haematoma  or  fibrinous  polypus.  From  its  almost  constant 
relationship  to  the  puerperium  it  is  commonly  known  as  a  '•  placental 
polypus,"  and  is  due  to  the  deposition  of  blood-clot  in  successive  layers 
upon  a  retained  portion  of  uterine  decidua  or  placenta.  The  blood 
tumour,  thus  formed  in  a  stalactitic  manner,  subsequently  becomes  or- 
ganised, and  may  remain  attached  to  the  uterine  wall  for  months.  Dur- 
ing the  time  of  its  formation  there  is  a  constant  hfemorrhagic  discharge, 
and  usually  at  the  period  of  its  expulsion  severe  and  copious  bleeding. 
Though  rarely  non-puerperal,  in  one  case,  fully  described  in  Ed.  Obstet. 
Transact  ions,  1893,  I  met  with  a  typical  example  in  a  non-puerperal 
patient,  who  suffered  from  intra-uterine  fibro-adenoma ;  the  case,  so  far 
as  I  can  learn,  is  unique.     The  roughened  surface  of  the  tumour  acts, 

2  k 


6io  SyST£A/  OF  GYNECOLOGY 

doubtless,  like  retained  portions  of  secimdines,  by  causing  blood  coagu- 
lation.    The  polypus  weighed  8  ozs. 

r.  W.  N.  Haultain. 


REFERENCES 

1.  Am.  J.  of  Obstet.  June  1895,  p.  652.  —  2.  Apostoli.  Trans.  French  Surgical 
Congress,  1889. — 3.  Aslanian.  Archiv.  de  Tocol.  et  gynaec.  Feb.  1895. — 4.  Bayle. 
Diction.  Paris,  vol.  vii.  p.  73. — 5.  Bernays.  Am.  J.  Obstet.  1895,  p.  357.  —  6.  Boldt. 
Am.  J.  Obstet.  1888,  p.  834.  — 7.  Bkown,  Baker.  Obstet.  Trans.  Land.  vol.  i.  p.  329.  — 
8.  Cabot.  Bost.  Med.  J.  June  1887.  —  9.  Champneys.  Practitioner,  Jauuary  1896.  — 10. 
Charrier.  Gazette  des  Hop.  1864.  — 11.  Cohnheim.  Varies,  v.  Algemeitie  Pathol,  p. 
641.  — 12.  Coussat.  Ballet.de  I'Acad.  Belgique,  lSti2.  —  IS.Cullingworth.  io»id.  Obstet. 
June  1876.  —  li.Ibid.  Obstet.  T?'ans.  London,  1S96. — 15.Dannion.  Electro-therapeutics, 
March  1888.  — 16.  Duchemin.  Thesis  sur  tumeur  fibroides  de  I'uterus,  1863.  — 17. 
Duncan.  Sterility  in  Woman,  p.  12.  — 18.  Ibid.  Obstet.  Trans.  Land.  1893.  — 19. 
Emmet.  Diseases  of  Women,  p.  572.  —  20.  Ibid.  Practice  of  Gynsecology.  —  21. 
Fergusson.  Land.  Obstet.  Trans,  vol.  i.  —  22.  Garceau.  Am.  J.  of  O&s^ei.  March 
1895,  p.  336.  —  23.  Gemmel.  Archiv  de  Tocologie,  vol.  i.  p.  700. — 24.  Greenhalgh. 
Med.  C'hir.  Trans,  vol.  lix.  p.  41. — 25.  Gurlt,  Von.  Langenbeck's  Arch.  \o\.  :s^v. — 
26.  GussEROw.  Neubild.  d.  Utei-us,  p.  203. — 27.  Ibid.  Archiv  f.  Gyndk.  vol.  i.  p. 
246.  —  28.  GuYON.  Tumeur  fbreuse  de  ruterus.— 29.  Haultain.  Ed.  Obstet.  Trans. 
vol.  xix.  —30.  Ibid.  vol.  xvlii.  p.  160.  —  31.  Hertz.  Virchow's  Archiv,  vol.  xlvi.  p. 
235.-32.  Hunter.  Am.  J.  Obstet.  vol.  xxi.  p.  62.-33.  Jesset.  Brit.  Gynsec.  J. 
1895. — 34.  Keith.  Ed.  Obstet.  Trans.  yo\.x\\.  — '65.  Klebs.  Handbuch  d.  Path.  Anat. 
1876.  —  36.  Klob.  Wiener  med.  Wochenschrift,  1863.  —  37.  Ibid.  Path.  Anat.  der 
Weibliche  Sex.  organ,  p.  173.  —  38.  Langenbeck,  Von.    Archiv  f.  Gyniik.  vol.  xxv. 

—  39.  Lee.  Med.  C'hir.  Trans.  Lond.  vol.  xxxiii.  p.  281. — 40.  Lefour.  Les  fibromes 
d' uterus  ail  point  de  vue  de  Gros.sesse. — 41.  Leopold  and  Fehling.  Archiv  f.  Gyn. 
vol.  vii.  p.  531. — 42.  Lisfranc.     Cliniq.  med.  de  la  hopit.  de  la  Pitie.    Paris,  1843. 

—  43.  M'Clintock.  Clin.  Mem.  on  Diseases  of  Women,  1863,  p.  97. — 44.  Marey. 
Trans.  Internal.  Med.  Cong.  1887,  vol.  ii.  p.  836.-45.  Mattel  Annal.  de  Gynaecol. 
vol.  vi.  — 46.  MiJLLER.  Archiv  f.  Gyndk.  1889,  p.  249.-47.  Murray,  Milne.  Ed. 
Obstet.  Tratis.  \o\.  XV. — 48.  Olshausen.  ^rc/i./.  GiynaA;.  vol.  viii.  p.  97. — 49.  Porak. 
Annal.  Gyndk.  vol.  xxvii.  p.  140. —50.  Pozzi.  Sydenham  ed.  p.  422. — 51.  Rhein. 
Archiv  f.  Gyn.  vol.  ix.  p.  414.  —  52.  Rindfleisch.  Path.  Geivebslehre,  1869,  p.  63.  — 53. 
RiEUX.  Bullet.  Soc.  Anat.  vol.  xxiv.  p.  19. — 54.  Routh.  Fibrous  Tumours  of  Womb, 
1864,  p.  26.-55.  Schroeder.  Lehrbuch,  p.  2.30. — 56.  Ibid.  Zeitschr.  f.  Geburt.  und 
Gyndk.  — 51.  Ibid.  vol.  i.  p.  89. —  58.  Simpson.  Obstet.  Works,  y>.  17,5.— 59.  Spiegel- 
berg.  Archiv  f.  Gyn.  vol.  vi.  p.  .345.  —  60.  Stratz.  Zeitsch.f.  Geburt.  u.  Gyndk.  vol. 
xvii.  — 61.  Susserot.  Inaug.  Dissert.  Rostock,  1870. —62.  Ibid.  1880.  — 63.  Tait. 
Diseases  of  TFome/i,  p.  194.  —  64.  Thorburn.  Diseases  of  Women,  p.  259.  —  65.  Tinns. 
Trans.  Obstet.  Soc.  London,  vol.  ii.— 66.  Turner.  Edin. Med.  Jour.  1864. —67.  Undbr- 
HiLL.  Ed.  Obstet.  Trans,  vol.  v. — 68.  Virchow.  Archiv,  vol.  iii.  —  69.  Ibid.  Gesch- 
vmlstleJire,  iii.  p.  195.  —70.  Wagnee.  Gebdrmutter  Krebs,  p.  13.  —  71.  Wyder.  Arch, 
f.  Gyndkol.  vol.  viii. 

F.  W.  N.  H. 


n  YS  TERE  C  TOM  V  6 1 1 


HYSTERECTOMY 

Hysterectomy  is  a  term  which  should  have  been  restricted  to  the  com- 
plete cutting  out  of  the  womb ;  unfortunately,  however,  it  was  in  common 
use  before  the  complete  extirpation  of  the  uterus  had  become  a  recognised 
operation,  so  we  can  only  accept  things  as  they  are,  and  under  this 
common  term  include  a  number  of  very  dissimilar  operations.  Thus  we 
have  this  term  hysterectomy  applied  quite  correctly  to  the  procedure  of 
complete  extirpation  of  the  uterus,  either  for  cancer,  sarcoma,  or  fibro- 
myoma,  and  equally  correctly,  whether  the  operation  be  performed 
through  the  abdomen,  through  the  vagina,  or  by  a  combination  of  those 
methods;  we  distinguish  these  several  raethods  SiS  abdommal,  vaginal, 
or  abdomino-vaginal  hysterectomy  respectively. 

But  the  term  hysterectomy  has  been  long  applied  to  a  class  of  opera- 
tions, in  Avhich  the  uterus,  at  any  rate  in  the  majority  of  cases,  has  been 
only  partially  removed,  and  in  many  merely  cut  into,  the  depth  of  the 
cutting  in  varying  from  the  complete  removal  of  a  portion  of  its  wall 
throughout  its  thickness  to  a  mere  incision  through  the  peritoneal  coat. 
These  procedures  would  have  been  better  classed  under  the  name 
myomectomy,  or  hystero-myomectomy. 

Since  the  operations  for  uterine  tumours  were  established  on  a  firm 
footing,  and  recognised  in  surgery,  it  has  become  the  usual  practice  when 
removing  fibromyomas  to  take  away  the  whole  upper  part  or  body  of 
the  uterus,  merely  leaving  the  cervix,  whether  the  operation  ended  as  an 
intraperitoneal  or  extraperitoneal  procedure :  these  operations  have  been 
very  generally  described  by  the  term  supravaginal  hysterectomy,  which 
distinguished  them  from  the  complete  extirpations  previously  referred  to. 
Now  it  is  becoming  increasingly  common  in  the  intraperitoneal  operations 
to  remove  the  whole  organ,  including  the  cervix ;  so  that  with  so  many 
very  different  operations  it  is  impossible,  except  by  prefix  and  by  the 
addition  of  explanatory  terms,  to  cover  all  with  one  name :  thus  we 
speak  of  vaginal  hysterectomy  for  cancer,  and  so  on.  Before  proceeding 
to  describe  these  various  operations,  it  is  necessary  very  briefly  to  refer 
to  the  diseases  and  conditions  which  render  them  advisable  or  necessary  ; 
I  say  advisable  or  necessary,  because  there  is  no  class  of  operations  in 
which  the  question  of  expediency,  as  distinguished  from  necessity,  so 
often  arises. 

Tumours  of  the  uterus  are  dealt  with  in  a  separate  article,  so  that  of 
these  I  shall  only  say  enough  here  to  make  my  meaning  clear.  Fibro- 
myoma,  or  fibroid  growth,  is  by  far  the  most  common  disease  leading 
to  the  question  of  operation;  then  come  cancer,  in  its  varying  forms, 
and  the  veiy  much  more  rare  sarcoma. 

Then  there  is  another  verv  distinct  class  of  cases  in  which  irreducible 


6i2  SYSTEM  OF  GYNAECOLOGY 

inversion,  or  complete  2)7'ocidentia,  may  raise  the  question  of  the  propriety 
of  hysterectomy.     The  operation  in  these  cases  is  always  vaginal. 

Certain  mcdformations  of  the  pelvis,  which  render  natural  child-birth 
impossible,'  may  also  give  rise  to  the  question  of  the  propriety  of  remov- 
ing some  part,  or  the  whole,  of  the  internal  sexual  organs. 

Fihromyoma  uteri  is  classified,  according  to  its  situation  in  the 
uterine  wall,  as  subperitoneal,  mural  or  intramural,  and  submucous. 
These  terms  sufficiently  explain  themselves ;  they  each  have  attached 
to  them  certain  definite  symptoms,  and  these  I  will  briefly  describe. 

Subperitoneal  growths  are  generally  multiple,  often  so  numerous  as  to 
form  a  complete  coating  to  the  whole  uterus,  hard  and  glistening  on 
section,  commonly  round  or  oval  in  shape,  covered  with  a  thin  and  usu- 
ally easily  separable  layer  of  peritoneum,  and  having  their  chief  blood 
supply  from  vessels  coursing  over  and  among  them,  rather  than  in  them. 
They  often  attain  a  very  great  size,  and  this,  and  the  irritation  they  set 
up  in  the  peritoneum  —  an  irritation  sometimes  leading  to  malignant 
disease  —  are  the  two  conditions  which  may  make  it  desirable  to  extirpate 
them.  Often  they  hardly  affect  the  size  or  shape  of  the  uterine  cavity 
at  all,  but  sometimes  they  elongate,  twist,  or  deform  it,  and  they  may 
then  cause  an  increase  of  menstrual  loss. 

Intramural  growths  often  appear  to  be  solitary ;  one  greatly  exceed- 
ing in  size  any  others  which  may  be  present.  They  usually  contain 
more  muscular  fibre  and  less  fibrous  tissue,  and  are  more  vascular; 
they  are  also  multiple,  but  rarely  to  the  same  extent  as  in  the  previous 
variety :  in  some  cases  almost  the  whole  uterine  wall  is  so  involved  in 
one  of  these  growths  that  it  appears  to  be  an  infiltration,  but  on  careful 
examination  of  such  a  specimen  it  will  be  seen  that  the  process  is  a 
pushing  aside  and  a  thinning  of  the  true  uterine  wall,  and  that  a  sort  of 
capsule  separates  the  growth  from  the  wall :  these  growths  also  attain 
a  great  size,  and  much  more  often  than  the  subperitoneal  growths  lead 
to  increased  menstrual  flow,  or  to  irregular  uterine  haemorrhage. 

Submucous  growths  do  not  differ  essentially  from  the  subperitoneal ; 
they  are  generally  multiple,  they  commonly  cause  hasmorrhage,  and  they 
often  greatly  enlarge  and  distort  the  uterine  cavity :  they  frequently 
become  gradually  separated  from  the  muscular  tissue  of  the  uterine  wall, 
except  at  one  spot  where  their  blood-vessels  enter,  and  thus  assume  a 
polypoid  form :  in  this  state  they  are  extruded  from  the  uterine  cavity, 
and  appear  in  the  vagina;  sometimes  they  slough  from  the  pressure 
exercised  upon  their  bases  and  blood-vessels  by  the  contracting  uterus, 
when  a  very  dangerous  condition  arises. 

All  three  varieties  may  involve  the  cervical  portion  of  the  uterus, 
though  obviously  tin;  sul)peritoneal  can  only  do  so  partially,  and  by 
extension  from  the  body  ;  their  presence  in  the  C(!rvix  is  often,  however, 
of  great  surgical  importance  in  deciding  whether  an  operation  be  feasible 
at  all ;  and,  if  so,  what  its  exact  nature  shall  be.  All  three  varieties  may 
be  found  in  the  same  individual,  but  more  often  one  kind  predominates, 


HYSTERECTOMY  613 


or  is  present  alone.  The  subperitoneal  and  intramural  most  often  attract 
attention  by  their  size ;  and  both,  in  their  early  stages,  are  apt  to  cause  a 
good  deal  of  pain,  especially  at  the  menstrual  periods :  the  intramural 
and  submucous  forms  most  commonly  first  make  their  presence  felt  by 
the  increased  flow,  irregular  losses,  and  pelvic  discomforts  or  actual  pain. 

Conditions  justifi/ing  Operation.  —  Great  and  rapid  increase  of  size, 
repeated  and  serious  htemorrhage,  and  severe  pain  were  thought  at  one 
time  to  be  the  only  justifications  for  operation.  Now,  however,  the  in- 
creasing success  of  the  operations  in  competent  hands,  and  the  generally 
improved  conditions  of  abdominal  surgery,  encourage  the  surgeon  to 
advise  operations  of  expediency  when  necessity  can  hardly  be  urged. 
Thus  a  patient  may  be  in  excellent  health,  and  yet  greatly  object  to  go 
through  life  carrying  a  great  tumour  in  her  abdomen.  When  the  con- 
ditions are  favourable  for  safe  removal,  such  a  patient,  in  my  opinion,  is 
qtxite  justified  in  seeking  relief  by  operation  ;  and  the  surgeon,  if  he  has 
had  sufficient  experience  in  such  cases,  is  quite  justified  in  operating.  I 
do  not  think  that  a  surgeon  without  special  experience  is  justified  in  per- 
forming these  operations ;  the  patient  is  nearly  always  well  enough  to  go 
to  a  special  operator,  and  the  inexperienced  cannot  appeal  to  emergency 
as  a  plea  for  interference.  In  some  cases  in  which  size,  haemorrhage, 
or  pain  make  an  operation  urgently  necessary,  it  may  be  impossible  to 
obtain  special  aid  ;  then  even  the  inexperienced  surgeon  may  feel  that  it 
is  his  duty  to  do  his  best.  Such  cases  are,  however,  rare ;  it  is  only  the 
specially  experienced  who  are  qualified  to  decide  as  to  the  fitness  of 
operations  of  expediency,  and  they  alone  should  perform  them. 

Fibrocysts  are  especially  interesting  to  the  surgeon,  as  being  often  so 
difficult  to  differentiate  from  ovarian  cysts,  and  also  on  account  of  their 
frequently  extremely  rapid  growth,  leading  to  urgent  necessity  for  opera- 
tion. Sometimes  their  cavities  are  full  of  blood  instead  of  serum. 
Their  pathology  is  of  great  interest,  but  I  must  refer  my  readers  to  the 
article  on  uterine  tumours  for  further  information  concerning  them. 

Myxomatous  Tumours.  —  One  form  of  tumour  deserves  a  special  notice, 
namely,  the  large,  soft,  myxomatous  fibromyoma :  it  often  attains  a  size 
so  enormous,  that  the  woman  appears  to  be  attached  to  the  tumour, 
rather  than  the  tumour  to  the  woman;  it  usually  burrows  deeply  into 
one  or  other  broad  ligament,  or  under  the  pelvic  or  abdominal  parietal 
peritoneum.  This  tumour  is  often  spoken  of  as  the  oedenuitous  fibro- 
myoma. I  have  seen  a  case  of  this  kind,  in  which  the  whole  peri- 
toneum lining  the  pelvis,  and  much  of  that  of  the  lower  part  of  the 
abdominal  cavity,  was  stripped  off  and  raised  upon  the  surface  of  the 
tumour,  so  that  the  latter  lay  in  immediate  relation  with  all  the  impor- 
tant vessels  and  nerves  supplying  the  lower  extremities,  and  with  the 
ureters.  In  such  a  case  adhesions  not  uncommonly  form  between  the 
tumour  and  these  imjiortant  structures,  conditions  which  have  to  be  kept 
in  mind  Avhen  discussing  operative  interference.  It  is  not  this  particidar 
kind  of  tumour  only  which  grows  into  the  broad  liganients,  or  inuler  the 
parietal  peritoneum ;  the  ordinary  fibromyoma  not  infrequently  does  so, 


6i4  SYSTEM  OF  GYNAECOLOGY 

and  I  shall  have  to  refer  again  to  the  increased  difficulty  and  danger 
encountered  in  operating  upon  such  cases. 

Sarcoma  of  the  titerus  is  very  rare,  and  probably  as  a  primary  disease 
seldom  appears  of  a  size  to  form  an  abdominal  tumour ;  it  is  commonly 
intra-uteriue,  and  closely  resembles  an  intramural  or  submucous  fibro- 
myoma  becoming  polypoid :  from  these  it  can  only  be  distinguished  by 
its  softness  and  the  rapidity  of  its  growth,  by  the  general  condition  of 
the  patient,  or  b}'  dilatation,  excision  of  a  portion  of  the  growth,  and 
microscopic  examination.  Primary  uterine  sarcoma  is  also  occasionally 
met  with  as  a  degenerative  growth  in  old  fibromyoma ;  it  is  a  degenera- 
tive change  in  the  cellular  tissue,  and  in  such  cases  may  form  a  very 
large  abdominal  tumour. 

Carcinoma  does  not  occur  as  a  degenerative  change  in  fibromyoma ;  it 
is  always  a  primary  disease. 

Adenoma  and  Carcinoma.  —  As  we  have  three  varieties  of  fibromyoma, 
so  we  have  practically  three  varieties  of  carcinoma ;  and  these  again  have 
special  seats  and  symptoms.  Adenoma  is  often  benign,  but  liable  in 
some  cases  to  recur  and  become  malignant. 

Columnar  epithelioma  of  the  glandular  type  attacks  both  the  body 
and  cervix ;  squamous  epithelioma  attacks  the  os,  and  is  also  found  in 
the  cervical  canal,  but  rarely  if  ever  reaches  the  cavity.  The  cohunnar 
variety  is  much  commoner  in  the  substance  of  the  cervix,  where  it 
probably  arises  from  the  cervical  glands,  than  in  the  uterine  cavity. 
Squamous  epithelioma  spreads  along  the  surface  more  than  it  penetrates ; 
columnar,  in  its  early  stages,  is  often  covered  in  by  healthy  tissue.  I 
need  not  dwell  upon  malignant  disease,  however,  as  it  is  dealt  with  in  a 
separate  article,  in  which  will  be  found  also  the  description  of  the  opera- 
tions suitable  for  its  removal,  including  those  Avhich  give  their  name  to 
my  article. 

In  dealing  with  the  operations  for  simple  tumour,  for  inversion  and 
procidentia,  and  for  malformations  interfering  with  natural  labour,  I 
shall  describe  them  as  I  am  in  the  habit  of  performing  them,  and  I  shall 
then  give  a  brief  description  of  such  additional  operative  procedures  as 
I  think  worthy  of  further  trial  and  consideration. 

Supravaginal  Hysterectomy  (Extraperitoneal).  —  The  stump  in  this 
operation  is  si-ciirHil  either  by  the  well-known  wire  serre-noeud  of  Koeberle 
—  I  always  use  this  myself  —  or  by  the  elastic  ligature ;  and  is  fastened 
into  the  lips  of  the  abdominal  wound  outside  the  peritoneum. 

Preparation  of  the  Patient.  — This  consists  in  a  careful  regulation  of 
the  bowels  Vjy  mild  aperients  and  enemata,  aided  by  a  somewhat  restricted 
and  light  diet,  for  a  Aveek  before  the  operation.  An  hour  before  the 
operation  the  site  of  tlie  incision,  the  pulxis,  and  vulva  are  well  washed 
with  carbolic  soap  and  water,  and  the  former  is  covered  with  a  thick  pad 
or  towel  wet  witli  1  to  20  carbolic  lotion,  and  applied  under  a  piece  of 
mackintosh  cloth  or  oil  silk  and  a  bandage.  Immediately  before  the 
patient  comes  into  the  operation  room  the  nurse  should  pass  the  catheter. 
Some  surgeons  tliink  this  is  not  necessary,  but  I  have  seen  very  experi- 


HYSTERECTOMY  615 


enced  operators  wound  a  full  bladder  in  making  the  peritoneal  incision, 
and  I  much  prefer  the  bladder  to  be  empty.  I  always  shave  the  pubes 
myself  jusu  before  I  operate,  and  after  the  patient  is  under  chloroform ; 
it  takes  a  few  seconds  only,  and  spares  the  patient  a  very  disagreeable 
process.  The  abdomen  and  chest  are  protected  by  an  india-rubber  sheet, 
a  hole  proportionate  to  the  expected  size  of  the  incision  being  cut  in  it, 
and  its  edges  coated  with  a  layer  of  carbolised  adhesive  plaster  an  inch 
and  a  half  broad. 

Operation.  —  When  operating  for  fibromyoma  the  incision  through 
the  peritoneum  must  be  made  with  a  little  more  care  than  in  ovariotomy, 
as  a  slight  wound  of  the  surface  of  the  tumour  may  cause  severe,  or  at 
any  rate  troublesome  liEemorrhage,  which  it  may  be  difficult  to  check  in 
the  dense  fibroid  mass.  As  soon  as  the  tumour  is  well  exposed,  and  all 
bleeding  from  the  edges  of  the  abdominal  incision  is  stopped  with  pressure 
forceps,  or  fine  silk  ligatures,  as  appears  more  desirable,  the  hand  is  intro- 
duced and  swept  over  the  abdominal  surfaces  of  the  tumour  to  estimate 
its  size,  and  to  detect  adhesions  if  there  be  any ;  it  is  then  passed 
into  the  pelvis  and  round  the  base  to  see  whether  it  will  be  necessary 
to  remove  the  ovaries  and  tubes,  and  whether  these  can  be  included  in 
the  wire  or  elastic  ligature,  or  must  be  tied  off  separately.  I  always 
leave  one  ovary  if  I  can,  as  I  find  that,  if  this  be  done,  the  patients 
recover  more  quickly  and  completely,  and  suffer  infinitely  less  at  the 
change  of  life ;  especially  do  they  escape  the  depression  which  is  apt  to 
follow  complete  removal  of  uterus  and  ovaries.  If  the  ovaries  and  tubes, 
or  an  ovary  and  tube,  have  to  be  tied  off,  I  apply  the  ligature  either  by 
transfixion  through  the  i;tero-ovarian  ligament  or,  if  this  be  impossible, 
as  it  often  is  in  these  cases,  through  a  thin  non-vascular  bit  of  the  broad 
ligament  pretty  near  the  side  of  the  uterus ;  then,  after  tying  off  the 
ovary  and  tube,  I  leave  one  loop  of  the  transfixing  ligatures  untied  to  be 
used  in  case  of  any  oozing  or  slipping  of  ligature  during  later  steps  of 
the  operation.  I  pass  the  serre-noeud  wire,  or  elastic  ligature,  through 
the  puncture  made  in  transfixing  the  right  broad  ligament,  and  again 
through  the  puncture  on  the  other  side  if  both  halves  of  the  broad 
ligament  are  tied  off.  If  the  broad  ligaments  are  not  tied  off  the  wire 
merely  passes  round  the  base  of  the  tumour,  including  one  broad 
ligament  and  transfixing  the  other,  so  as  to  exclude  the  ovary  and  tube 
on  that  side.  If  the  tumour  be  very  large  and  vascular,  and  the  broad 
ligament  much  opened  up,  it  is  desirable  to  apply  two  temporary  clamps 
on  the  sides  of  the  uterus,  and  to  cut  the  broad  ligament,  between  them 
and  the  ligatures,  down  to  the  transfixion  punctures;  this  greatly  frees 
the  tumour,  and  renders  the  tightening  up  of  the  constricting  material 
much  easier.  In  many  cases  it  is  necessary,  before  screwing  up,  to  peel 
back  the  peritoneum  both  in  front  and  behind,  first  carrying  a  nearly 
horizontal  incision  just  through  the  thin  peritoneal  covering  (so  as  to 
avoid  any  visible  vessels)  from  one  transfixion  point  to  the  other,  and 
then  to  push  it  down  with  the  fingers,  so  that  the  wire  or  rubber  is 
applied  on  the  denuded  surface,  and  all  chance  of  drawing  in  the  bladder 


6i6  SYSTEM  OF  GYNECOLOGY 

or  the  ureters  is  avoided.  In  the  great  majority  of  cases  it  is,  in  fact, 
better  to  push  down  the  bladder  in  this  way ;  the  posterior  enucleation 
is  rarely  required.  After  the  wire  or  ligature  is  tightened  up,  a  strong 
pin  with  a  little  screw  cap  is  passed  through  the  uterus  from  side  to 
side  just  above  the  wire ;  sponges  are  packed  all  round,  and  the  whole 
tumour  and  uj)per  part  of  uterus  are  rapidly  cut  away,  special  care  being 
taken  to  dry  up  at  once  any  mucus  or  fluid  which  exudes  when  the 
uterine  cavity  is  cut  across.  In  the  great  majority  of  cases  section  takes 
place  near  the  internal  os,  and  only  a  small  opening,  filled  with  a  little 
plug  of  mucus,  is  seen  in  the  middle  of  the  stump ;  but  sometimes  a 
lai-ge  bloody  cavity  is  opened,  and  then,  unless  great  care  be  taken, 
fouling  of  the  peritoneum  may  easily  occur.  To  cleanse  this  cavity  I 
always  use  absorbent  cotton  soaked  in  pure  tincture  of  iodine,  or  in 
yJy-fj-  corrosive  sublimate  solution.  There  is  usually  some  shrinkage  of 
the  tissues  included  in  the  wire  or  rubber  ligature  after  the  tumour  is 
cut  away,  and,  if  the  enclosed  stump  be  large,  it  may  be  necessary  to 
tighten  up  the  screw  of  the  serre-noeud  several  times  during  the  con- 
cluding steps  of  the  operation. 

I  have  described  the  procedure  without  any  mention  of  adhesions ; 
if  they  are  present,  especially  if  they  are  omental,  they  often  contain 
enormous  vessels,  and  in  separating  them  great  care  is  required  to 
avoid  serious  loss  from  the  uterine  side  after  they  are  tied  and  divided 
on  their  proximal  side.  Wells'  large  pressure  forceps,  and  the  square- 
ended  ones  which  bear  my  own  name,  are  very  useful  for  such  adhesions. 
Adhesions  of  large  surfaces  of  intestine  are  exceeding  difiicult  to  deal 
with ;  there  is  no  room  to  apply  ligatures  before  separating,  and  no 
room,  or  not  firm  enough  tissue,  to  apply  pressure  forceps  after  separa- 
tion ;  thus  both  surfaces  frequently  ooze  very  freely,  and  much  blood 
may  be  lost  during  the  future  steps  of  the  operation :  these  patients  can 
rarely  spare  blood ;  sponge  pressure  is  the  only  way  of  dealing  with 
these  oozing  surfaces.  The  raw  intestinal  surfaces  often  require  fine  silk 
to  be  passed  carefully  under  the  peritoneal  and  into  the  muscular  coat, 
and  drawn  together  bag-mouth  fashion,  to  check  the  oozing  when  the 
tumour  has  been  got  rid  of,  and  before  closing  up.  If  there  is  likely  to. 
be  much  oozing  after  the  peritoneum  is  closed,  I  use  a  Keith's  glass 
tube  passed  to  the  bottom  of  the  pelvis  as  in  ovariotomy  ;  and  I  usually 
bring  it  out  rather  high  up  in  the  abdominal  incision,  so  as  to  tie  two 
or  three  sutures  between  it  and  the  stump,  and  get  room  for  some  dry 
antiseptic  dressing  between ;  for  the  stump  in  most  cases  soon  becomes 
septic.  For  the  same  reason  I  always  get  rid  of  the  tube  as  soon  as 
Y)0ssible  after  the  operation :  I  believe  the  presence  of  much  fluid  in  the 
drainage  tube  after  the  first  thirty-six  or  forty-eight  hours  is  often  a  sign 
that  the  tube  is  irritating  a  sensitive  peritoneum,  a  i)oint  which  can  be 
tested  by  sli]j])ing  a  fine  rubber  tul)e  through  the  glass  one  when  the 
latter  is  withdrawn,  and  the  former  is  left  for  another  twelve  or  twenty- 
four  hours :  if  the  discharge  then  quickly  diminish  the  tube  can  be  re- 
moved entirely  ;  if  it  continue,  sufficient  drainage  is  lu'ovided.     Septicity 


HYSTERECTOMY  617 


of  the  discharge  is  sometimes  indicated  by  a  prolonged  or  increased 
flow  from  the  tube,  and  this  without  the  smallest  perceptible  odour ;  so 
that  removal  of  the  glass  tube  must  be  carefully  considered  whenever 
there  is  anything  abnormal  either  in  the  quantity  of  the  flow  or  in  its 
duration. 

For  ligatures  and  sutures  I  still  prefer  pure  Chinese  silk  twist  well 
soaked  in  1  to  20  carbolic  solution :  JSTo.  1  for  adhesions,  or  Xo.  0  for 
very  fine  intestinal  work ;  Ko.  2  for  sutures  ;  No.  3  for  a  special  strong 
suture  in  these  cases  above  and  below  the  stump,  and  ISTo.  3  for  tying 
the  broad  ligaments.  I  sometimes  use  No.  4  for  temporary  tying  off  of 
parts  during  a  difficult  operation,  but  never  to  leave  in  the  peritoneum. 
I  believe  that  the  use  of  too  thick  silk  is  a  fruitful  source  of  the  pelvic 
swellings,  abscesses,  and  sinuses,  about  which  I  am  not  infrequently  con- 
sulted, but  which  I  am  happy  to  say  are  unknown  in  my  own  practice. 
I  have  even  heard  of  No.  5  being  used  to  tie  an  ordinary  ovarian 
pedicle ;  I  do  not  think  I  ever  had  a  skein  of  this  size  in  my  possession, 
even  in  my  early  days  when  I  had  not  fully  tested  the  wisdom  of  using 
the  finest  silk  which  would  do  the  work  required  of  it.  After  the  closure 
of  the  abdomen  I  pare  down  the  stump  as  much  as  possible,  especially 
cutting  away  the  inside  fibrous  and  muscular  tissue  into  a  somewhat 
cupped  shape ;  pack  it  firmly  round  with  dry  carbolic  gauze ;  and  then 
with  great  care  apply  a  little  solid  perchloride  of  iron  to  the  cut  surface  : 
this  agent  must  be  used  very  sparingly  and  carefully,  as  it  causes  a  flow 
of  acid  serum,  which  is  very  dangerous  if  it  trickle  into  the  peritoneum ; 
but  I  am  sure  it  is  a  great  safeguard  if  properly  used.  First,  if  the  con- 
striction of  the  wire  relax  at  all  through  shrinkage  during  the  first  few 
hours  after  the  operation,  it  effectually  prevents  any  oozing  from  the 
stump ;  secondly,  it  dries  and  tans  the  stump,  so  that  putrefaction  from 
the  central  cavity  spreads  into  it  very  slowly,  and  only  after  some  days 
Avhen  the  parts  round  about  are  sealed,  and  putrefaction  is  no  longer  so 
dangerous.  I  altogether  disapprove  of  sewing  over  the  peritoneal  edges 
of  the  stump ;  it  is  quite  useless  if  the  perchloride  of  iron  be  used,  and 
must  in  any  case  shut  up  material  which  is  much  better  escaping  freely  into 
the  dressings  at  once.  I  have  seen  half  an  hour  wasted  over  this  sewing 
up  of  the  stump,  when  the  operation  had  already  been  long  enough  to  tax 
the  patient's  strength  to  the  utmost. 

After  Treatment.  —  I  sometimes  arrange  so  that  the  screw  of  the  serre- 
noeud  can  be  exposed  "without  disturbing  the  rest  of  the  dressing,  and  a 
screw  up  given  to  it  every  twelve  or  twenty -four  hours ;  but  this  is  only 
necessary  with  very  thick  stumps,  and  in  most  cases  it  is  best  to  leave 
the  dressings  undisturbed  for  several  days,  and  then  change  everything, 
dusting  all  the  time  with  a  pepper  dredger  full  of  finely  powdered  boracic 
acid.  The  second  dressing  comes  about  the  eighth  day,  and  then  alter- 
nate sutures  are  removed.  I  generally  leave  the  last  two  or  three  sutures 
a  good  deal  longer  in  these  cases  than  after  ovariotomy,  as  the  wounds 
are  especially  liable  to  reopen.  I  suppose  the  firm  wedge  of  pedicle  has  a 
tendency  to  draw  open  the  wound ;  certain  it  is  that  these  incisions  require 


6i8  SYSTEM   OF  GYNAECOLOGY 

far  more  care  during  convalescence  than  wounds  in  wliicli  the  abdominal 
cavity  is  completely  closed.  The  gaping  of  a  wound  after  removal  of 
the  sutures  was  a  much  more  frequent  occurrence  in  the  old  clamp  days 
of  ovariotomy  than  now ;  and  in  both  cases  the  presence  of  sepsis  in  the 
lower  part  of  the  wound  probably  retards  firm  healing  throughout. 

The  treatment  of  the  stump  varies  according  to  its  size  and  thickness. 
If  the  part  enclosed  in  the  wire  be  small,  I  generally  screw  it  up  at  the 
early  dressings,  and  then  leave  it  alone  till  it  sloughs  off ;  if  it  be  a  thick 
pedicle  I  clip  it  well  down  at  each  dressing  after  screwing  it  up,  and 
very  often  clip  it  down  to  the  wire  and  pin  at  the  end  of  two  weeks 
and  remove  them :  the  remaining  slough  I  leave  to  separate  by  itself, 
merely  clipping  away  loose  shreds.  This  necessary  sloughing  and 
separation  of  the  stump  are  the  weak  points  in  this  extraperitoneal 
operation.  The  process  is  attended  by  a  certain  risk  of  septic  absorption, 
especially  if  the  surgeon  is  too  much  inclined  to  pull  the  stump  about 
at  the  dressings ;  it  makes  the  convalescence  tedious ;  often  five  or  six 
weeks  elapse  before  it  is  entirely  gone,  and  even  more  before  the 
granulating  cavity  is  closed  up ;  and,  when  cicatrisation  is  complete  it 
often  leaves  a  weak  place  in  the  scar.  In  spite  of  these  obvious  dis- 
advantages I  still  prefer  this  method  in  the  great  majority  of  cases  to 
any  of  the  modifications  which  have  been  proposed ;  certainly  in  my 
own  hands  it  has  yielded  a  greater  number  of  good  recoveries  than  the 
intraperitoneal  method  which  I  shall  now  describe. 

Supravaginal  Hysterectomy  (Intraperitoneal).  —  In  this  operation 
the  stump  is  secured  by  ligatures  and  sutures,  its  peritoneal  edges  are 
brought  together  over  its  whole  surface,  and  it  is  then  dropped  into  the 
peritoneum  as  is  the  stump  of  the  pedicle  in  an  ordinary  ovariotomy. 
The  ditference  between  these  two  stumps  is  not,  however,  sufficiently 
considered  by  those  who  advocate  this  method.  Unless  the  needles 
or  ligatures  used  by  the  surgeon  contain  septic  materials,  the  ovarian 
pedicle  stump  contains  nothing  but  sound  uncontaminated  tissues ;  the 
uterine  stump,  on  the  other  hand,  always  contains  in  its  centre  a  cavity 
which  it  is  impossible  to  render  certainly  aseptic  ;  in  some  cases,  no  doubt 
we  can  clean  the  uterine  cavity  with  strong  antiseptics  just  before  the 
operation,  but  this  procedure  is  extremely  difficult  or  even  impossible 
when  the  cavity  is  very  irregular  in  form,  and  twists  and  turns  about  in 
the  tumour,  and  we  can  never  be  sure  that  our  aj^plications  have  been 
so  thorough  as  completely  to  clean  away  all  possible  sources  of  con- 
tamination :  then,  if  any  septic  material  be  left  it  lies  right  in  the  centre 
of  the  stump,  and  in  immediate  contact  with  tissues  rendered  specially 
prone  to  decay  by  tlie  interference  with  their  nutrition  caused  by  the 
constricting  ligatures  and  sutures,  and  l)y  the  rough  handling  they  have 
had  during  the  separation  of  the  tumour  from  its  base.  That  this  is  a 
very  grave  objection  to  this  particular  method  its  statistics  show ;  and 
the  danger  is  greatly  increased  by  the  occasional  occurrence  of  haimor- 
rhagf  into  the  stump  which,  even  when  not  sufficient  in  amount  to  be 


HYSTERECTOMY  619 


dangerous  as  hsemorrhage,  adds  greatly  to  the  risk  of  septicsemia  from 
the  additional  material  it  gives  for  infection,  and  from  the  still  further 
interference  with  the  nutrition  of  the  stump  tissues.  Hsemorrhage  to 
a  fatal  issue  is  also  still  one  of  the  risks  of  any  complete  intraperitoneal 
method,  though  this  has  been  greatly  reduced  with  increase  of  experi- 
ence in  the  securing  of  the  vessels,  and  in  the  application  of  the  con- 
stricting ligatures  and  sutures  to  the  stump. 

I  need  not  recapitulate  the  steps  in  the  operation,  which,  up  to  the 
time  when  the  tumour  is  freed  from  adhesions,  if  any,  and  brought  out- 
side the  abdomen,  are  exactly  the  same  as  in  the  one  just  described.  If 
the  base  of  the  tumour  be  sufficiently  clear  of  the  lower  segment  of  the 
uterus  for  the  passing  of  a  ligature  round  the  whole  base,  including  the 
ovaries  and  tubes  —  or  round  one  ovary  and  tube,  if  the  other  is  to  be 
left  behind  —  a  strong  piece  of  red  rubber  tube  is  passed  round,  firmly 
drawn  up,  and  its  crossed  ends  secured  in  a  pair  of  large  pressure  forceps  ; 
then  a  pin,  similar  to  that  used  in  the  other  operation,  is  passed  through 
the  uterus  and  one  or  both  broad  ligaments,  close  to  the  upper  side  of 
the  ligature,  and,  sponges  being  packed  round  the  tumour,  it  is  cut  away  ; 
great  care  must  be  taken  to  leave  a  sufficiently  large  stump,  and  espe- 
cially a  broad  margin  of  the  peritoneal  covering.  One  or  both  broad 
ligaments,  according  as  one  ovary  or  both  is  to  be  removed,  are  then 
secured  by  transfixion  in  the  usual  way  ;  the  inner  loop  of  the  transfixing 
ligature  being  left  untied  for  future  use  if  required,  as  described  in  the 
extraperitoneal  method.  The  uterine  arteries,  which  can  be  readily  felt 
pulsating,  are  now  separately  secured  by  transfixion,  care  being  taken  to 
carry  the  needle  close  to  the  cervix,  and  to  remember  how  close  in  this 
situation  the  ureters  lie  to  the  uterine  arteries.  The  stump  is  then  care- 
fully pared  down  to  the  size  and  shape  in  which  it  is  to  be  left,  and  a 
deep  cup  made  in  it  by  paring  out  its  centre ;  the  mucous  membrane  is 
cut  away  right  down  to  the  level  of  the  constricting  ligature  :  then,  if  it 
be  possible,  a  fine  probe  armed  with  cotton  wool  soaked  in  some  powerful 
antiseptic  should  be  passed  through  the  centre  of  the  stump  into  the 
vagina;  some  operators  use  the  cautery  for  this,  but  I  do  not  think 
the  plan  a  good  one ;  it  may  destroy  the  septic  material,  but  it  leaves  a 
layer  of  dead  tissue,  and  below  this  a  layer  of  damaged  tissue  in  the 
stump,  just  when  we  Avant  everything  to  be  as  healthy  and  as  capable 
of  quiet  repair  as  possible.^  After  the  cleansing  is  as  perfect  as  it  can 
be  made,  the  edges  of  the  mucous  opening  are  carefully  brouglit  together 
by  a  few  points  of  fine  silk  interrupted  suture  which  are  cut  short ;  then 
the  deeper  parts  of  the  muscular  tissue  are  brought  firmly  together  b}^ 
another  row  about  half  an  inch  from  the  first  sutures ;  then  the  constrict- 
ing band  is  relaxed,  and  pressure  forceps  are  applied  to  bleeding  points, 
which,  however,  will  be  few  if  the  broad  ligaments  and  uterine  arteries 
have  been  efficiently  dealt  with :  after  a  pause,  to  allow  anything  that 

1  It  will  be  seen  faiili(>r  on  in  this  article,  that  recent  observations  sliow  that  in  most 
cases  the  cervical  canal  docs  not  contain  putrefactive  organisms,  and  this  demonstration 
may  modify  our  practice  in  this  particular. 


620  SYSTEM  OF  GYNAECOLOGY 

is  going  to  bleed  to  show  itself,  all  the  points  in  the  forceps  are  carefully 
secured  by  fine  silk  passed  with  a  fine  needle  under  the  open  mouth 
of  the  vessel,  the  pin  is  removed,  and  the  peritoneal  edges  are  brought 
firmly  together  over  the  surface  of  the  stump,  first  by  a  row  of  inter- 
rupted sutures,  and  then  by  a  fine  continuous  suture,  so  applied  as  to  bury 
the  first  row  between  inverted  peritoneal  surfaces ;  the  stump  is  then 
allowed  to  sink  back  into  the  pelvis,  and  the  abdominal  incision  entirely 
closed,  unless  it  be  thought  desirable  to  drain,  in  which  case  a  Keith's 
glass  tube  is  passed  down  beside  the  stump,  and  its  mouth  closed  with  the 
usual  rubber  sheet  and  sponge  dressing.  Some  of  the  cases  in  which  I 
have  performed  this  operation  have  made  remarkably  quick  and  satis- 
factory recoveries  ;  others  have  had  evidence  of  serious  trouble  in  and 
around  the  stump  :  in  one  case  the  Avhole  cervix  sloughed  out  and  was 
discharged  into  the  vagina,  the  patient  eventually  making  a  good  recovery. 
But  what  has  chiefly  deterred  me  from  more  frequently  operating  by 
the  intraperitoneal  method  is  the  occasional  fatality  from  hsemorrhage. 
I  lost  some  cases  myself  in  my  early  operations,  and  though  I  have  not 
had  this  misfortune  now  for  many  years,  I  see  occasional  reports  of 
them :  moreover,  I  have  reason  to  know  that  others  happen  which  are 
not  reported ;  and  I  greatly  doubt  whether  the  intraperitoneal  method 
would  hold  its  own,  if  really  reliable  statistics  of  the  extra-  and  intra- 
peritoneal methods  could  be  obtained. 

Comparison  of  Results  obtained  by  the  Two  Methods.  —  In  order  to 
satisfy  myself,  in  so  far  as  my  own  results  go,  whether  my  impressions 
were  correct,  I  have  been  most  carefully  through  my  case  books,  and 
weeded  out  all  the  cases  in  which  some  unusual  complication  —  such  as 
pregnancy,  the  presence  and  removal  of  a  large  ovarian  tumour,  or  the 
presence  and  removal  along  with  the  fibromyoma  of  a  large  suppurating 
calculous  kidney  —  could  specially  affect  the  result.  I  then  classified 
the  cases  according  to  the  extent  of  the  operation,  and  the  method  of 
dealing  with  the  remains  of  the  uterus.  I  find  that  the  results  completely 
bear  out  the  impressions  I  had  formed,  or  rather  support  still  more 
strongly  the  extraperitoneal  method,  with  Koeberle's  serre-nceud  for  the 
ordinary  run  of  cases.  Complete  removal  of  the  uterus,  including  the 
cervix,  has  succeeded  still  better,  all  my  cases  having  recovered ;  but 
they  are  few,  and  the  method  is  not  suitable  for  all  cases. 

I  have  not  only  weeded  out  such  cases  as  I  have  named  above,  but 
I  have  put  into  a  separate  class  those  formidable  cases  in  which  a  very 
large  tumour  grows  either  into  (between  the  folds  of)  the  broad  liga- 
ment, or  under  the  peritoneum  ;  cases  in  which  a  large  amount  of  enu- 
cleation has  to  precede  the  formation  of  a  pedicle,  and  in  which  a  large 
ragged  cavity  is  left  ])eside  the  stump,  cither  in  the  broad  ligament  or 
under  the  pai'ietal  peritoneum.  At  a  recent  discussion  in  America  it  was 
proposed,  and  I  think  very  properly,  to  consider  these  cases  as  a  separate 
class.  Operations  for  the  removal  of  such  tumours  are  among  the  most 
formidable  the  surgeon  has  to  perform,  and  among  the  most  dangerous 
to  the  life  of  the  patient.     It  is  absurd,  therefore,  to  class  them  with 


HYSTERECTOMY  621 


cases  in  which  the  wire  of  the  serre-noeud  encloses  the  whole  uterine 
pedicle  and  one  or  both  ovaries ;  or  in  which  the  wire  readily  takes  the 
pedicle  after  the  ovary  or  ovaries  have  been  tied  off. 

The  results  of  my  research  are  as  follows :  —  Cases  in  which  the  serre- 
nffiud  could  be  employed  without  extensive  enucleation  ha^'C  a  mortality 
of  just  under  8  per  cent.  Cases  in  which  a  formidable  enucleation  has 
to  be  done  have  a  mortality  of  32  per  cent.  Cases  treated  by  ligature 
and  suture  (intraperitoneal)  have  a  mortality  of  50  per  cent.  Removals 
of  solid  outgrowths  (subperitoneal  tumours),  or  of  pediculate  fibroc^^sts, 
or  enucleation  of  cysts,  in  all  of  which  the  uterine  cavity  is  not  opened 
into,  have  only  a  mortality  of  7  per  cent.  Those  in  which  the  cavity  is 
opened,  but  the  body  of  the  organ  not  removed,  have  in  my  experience 
been  the  most  fatal  of  all ;  but  their  number  is  too  small  to  permit  a 
statistical  appreciation  of  results. 

Cases  in  which  the  Avhole  uterus  has  been  dissected  out  have,  as  I 
have  said,  all  recovered. 

In  looking  at  these  results  it  must  be  borne  in  mind  that  they  include 
all  my  early  work  when  the  Avhole  of  these  operations  were  in  their 
infancy,  and  only  occasionally  attempted ;  and  as  I  early  became  dis- 
satisfied with  the  intraperitoneal  method,  my  results  under  this  head 
belong  to  my  early  work  alone :  doubtless  had  I  worked  more  at  it  the 
results  would  have  improved,  but  the  gap  between  8  per  cent  and  50 
per  cent  wants  a  good  deal  of  bridging  over.  Then  also  it  must  be 
borne  in  mind  that  this  8  per  cent  mortality  includes  all  my  early  work 
with  the  serre-noeud ;  and,  as  practice  with  it  has  reduced  this  mortalit}^ 
l^y  fully  one-half,  the  cases  which  are  suitable  for  the  serre-noeud,  and  in 
which  there  is  no  unusually  serious  complication,  may  fairly  be  said  in 
experienced  hands  to  have  a  mortality  of  only  3  or  4  per  cent.  My  im- 
pression is  that  my  results  in  the  series  of  enucleation  cases  would  have 
been  better  if  I  had  performed  a  true  hysterectomy,  and  excised  the 
remains  of  the  cervix  as  well.  It  is  the  combination  of  the  large 
ragged  cavity,  from  which  the  base  of  the  tumour  has  been  enucleated, 
with  the  sloughing  stump  which  leads  to  the  high  mortality  in  this  class 
of  cases. 

The  manifest  objections  to  the  extraperitoneal  treatment  of  the 
stump,  and  the  search  after  some  surgically  complete  and  satisfactory 
intraperitoneal  method,  have  led  to  a  large  number  of  suggestions ;  some 
good  and  likely  to  bear  good  fruit,  and  more  bad  and  siire  to  die  j^rac- 
tically  stillborn.  American  surgeons  are  now  rather  taking  the  lead  in 
this  new  departure.  German,  French,  and  Belgian  surgeons  run  them 
hard,  however,  Avith  novelties  in  method,  and  some  excellent  results. 
Great  Britain  seems  to  be  dropping  a  little  behind,  and  resting  on  the 
extraperitoneal  method ;  though  we  shall  certainly  have  to  reconsider 
the  question  with  such  results  from  intraperitoneal  work  as  have  been 
obtained  by  Baer,  Zweifei*,  Chrobak,  Pean,  Richelot,  Doyen,  Jacobs, 
Martin,  Bardenhauer.  Eastman,  and  others. 

I  now  proceed  to  describe  some  of  the  suggested  modifications  in  the 


622  SYSTEM   OF  GYiV.-ECOLOG  V 

intraperitoneal  methods  which  I  think  most  valuable  and  likely  to  sur- 
vive ;  and  I  shall  also  mention  some  that  I  do  not  think  well  of  in 
order  to  point  out  objections  and  to  warn  off  my  readers  from 
them. 

Before  proceeding  to  describe  some  of  the  best  of  the  many  modifica- 
tions recently  suggested  and  practised  inthe  performance  of  this  operation, 
it  will  not  be  out  of  place  to  give  a  brief  account  of  the  early  work  at  the 
operation,  and  its  gradual  establishment  among  the  recognised  surgical 
procedures.  The  early  operations  were  nearly  all  stumbled  into  when 
the  surgeon  expected  to  perform  ovariotomy ;  and,  as  might  be  expected 
of  an  operation  which  still,  with  all  our  advances  and  experience,  often 
taxes  to  the  utmost  the  skill  and  nerve  of  our  most  expert  specialists, 
they  usually  ended  in  disaster.  Then  came  Koeberle's  serre-noeud  and 
a  new  era  dawned.  Pean  in  Paris,  Koeberle'  himself,  Kaltenbach  and 
Hegar  in  Germany,  Keith  in  Scotland,  and  Bantock  and  myself  in  London, 
each  did  a  considerable  number  of  cases,  and  chiefly  difficult  cases  with 
large  tumours,  because  it  was  only  in  such  that  it  was  considered  jus- 
tifiable to  operate  at  all ;  and  yet  the  success  was  very  fair.  Now  and 
again  it  was  found  impossible  to  apply  the  serre-noeud,  and  some  intra- 
peritoneal method  was  adopted,  with  some  increase  of  knowledge  for 
the  surgeon,  but  only  very  occasionally  with  a  result  satisfactory  to  the 
patient.  When  an  intraperitoneal  case  did  succeed,  the  convalescence 
was  more  rapid,  and  the  immediate  result  more  satisfactory,  than  with 
the  extraperitoneal  method.  I  did  my  first  operation  at  the  Samaritan 
Hospital  in  January  1877,  choosing  deliberately  the  intraperitoneal 
method,  and  securing  the  stump  by  silk  ligatures  with  a  successful  result, 
nearly  two  years  before  Schroeder  first  called  attention  to  that  intra- 
peritoneal method  which  will  always  be  associated  with  his  name. 
Disappointed  by  results  in  succeeding  cases,  I  tried  to  improve  my 
intraperitoneal  method,  but  without  much  success.  I  had  not  then 
fully  adopted  Listerism  in  abdominal  surgery,  and  I  fell  back  upon  the 
extraperitoneal  method,  using  Koeberle's  serre-noeud,  and  a  single  pin 
devised  by  myself  to  support  the  stump.  Schroeder  first  suggested  his 
method  in  187S,  but  did  not  fully  publish  it,  with  cases,  till  1882,  and 
he  had  a  mortality  of  30  per  cent,  a  rate  which  was  never  improved  to 
the  end  of  his  work,  which  consisted  of  164  cases,  published  by  Hofmeir. 
Some  of  his  followers,  however,  were  much  more  successful.  Breunicke 
of  Magdeburg  had  a  series  of  twenty-one  cases,  all  successful.  Fritsch  of 
Breslau,  having  by  the  extraperitoneal  method  reduced  his  death-rate  to 
7  per  cent,  was  still  dissatisfied,  and  went  to  Schroeder's  method,  with 
what  success  I  do  not  know. 

Baer's  Operation. —  In  1891 B.  F.  Baer  of  Philadelphia  first  performed 
this  operation,  and  in  the  following  year  he  published  the  method  with 
some  successful  cases.  I  give  it  the  first  place  among  the  new  procedures 
wliich  I  describe,  because  I  think  it  is  the  most  surgical,  and  at  the  same 
time  the  most  likely  to  give  good  results  in  the  hands  of  competent  imi- 
tators.    His  own  results  have  been  splendid.     I  give  the  details  of  the 


HYSTERECTOMY  623 


operation  as  first  published  by  him  in  the  Transactions  of  the  American 
Gyncjecological  Society,  vol.  xvii.  1892,  p.  234. 

The  ovaries  are  tied  off  by  a  single  ligature  passed  close  to  the  side  of 
the  tumour,  and  not  including  the  tubes,  the  ligatu.re  being  also  passed 
through  the  outer  edge  of  the  broad  ligament ;  then  the  uterine  arteries 
are  separately  ligatured  on  each  side,  the  tumour  and  uterus  are  cut  away, 
any  points  of  hcemorrhage  are  secured  by  separate  ligatures,  and  the 
cervical  stump  is  allowed  to  drop  back  into  the  peritoneum.  The  retrac- 
tion aids  in  stopping  any  small  hsemorrhage,  and  the  edges  of  the  broad 
ligament  close  in  over  the  stump,  so  that  there  is  no  need  for  suturing  of 
flaps  over  it :  he  does  not  object  to  this,  however,  if  it  appear  necessary  in 
any  special  case.  The  mucus  plug  in  the  cervical  canal  is  not  disturbed 
either  before  or  during  the  operation  ;  and  on  this,  and  on  the  absence  of 
all  ligatures  or  sutures  in  the  stump,  he  lays  great  stress.  He  claims  for 
this  procedure  that  the  vaginal  portion  of  the  cervix  maintains  its  position 
as  the  keystone  of  the  vaginal  arch,  and  preserves  the  strength  and  shape 
of  the  lower  part  of  the  abdominal  cavity.  He  does  not  fear  any  serious 
haemorrhage  from  the  cut  surface  of  the  cervix  if  the  ovarian  and  uterine 
arteries  have  been  securely  ligatured ;  and  he  does  not  believe  in  the 
necessity  for  any  drainage  in  abdominal  surgery.  The  method  at  once 
commends  itself  to  the  surgical  mind.  Doderlein's  researches,  which 
show  that  the  cervical  canal,  when  not  interfered  with,  does  not  contain 
septic  organisms,  give  great  support  to  Baer;  but  in  many  patients  the 
cervical  canal  has  been  interfered  with  before  they  come  to  the  operation  ; 
in  others  the  section  has  to  be  made  through  a  large  open  canal  full 
of  clot  or  bloody  mucus,  yet  in  Baer's  papers  I  fail  to  find  any  suggestion 
for  dealing  successfully  with  these  cases.  The  plug  does  frequently  exist, 
and  I  have  already  in  this  paper  referred  to  its  presence,  but  I  did  not 
appreciate  its  value  till  I  read  Baer's  paper. 

Baer  published  a  second  paper  on  his  method  in  the  same  Transactions, 
vol.  xviii.  p.  62.  In  this  he  says  :  "  The  vital  principles  in  supravaginal 
hysterectomy  are  —  first,  control  of  hsemorrhage  by  ligature  of  the  blood- 
vessels in  the  broad  ligaments  ;  second,  non-constriction  of  the  cervical 
tissues,  so  that  there  shall  be  no  cause  for  suppuration  ;  and,  third,  non- 
disturbance  of  the  cervical  canal,  so  that  sepsis  from  the  vagina  may  be 
prevented." 

Dudley  and  Goffe's  Operation.  —  I  mention  this  operation  next,  not 
because  I  wish  to  commend  it,  but  because  the  authors  have  claimed  for 
it  that  it  is  like  Baer's  operation,  —  a  claim  which,  to  my  mind  as  to 
his,  shows  how  little  they  have  appreciated  the  points  of  his  procedure. 
They  ligature  the  cervix  by  ligatures  passed  under  or  inside  its  peritoneal 
covering,  and  then  they  cover  in  the  raAv  surface  Avith  large  peritoneal 
flaps  cut  without  any  other  tissue  in  them,  and  sewn  over  the  stump  so 
as  to  shut  it  off  from  the  peritoneal  cavity.  What  is  the  result  ?  That 
in  order  to  let  out  the  pus  which  often  accumulates  between  its  raw 
surface  and  the  flaps,  they  have,  soon  after  operation,  to  place  their 
patients  in  the  position  for  dilatation  of  the  cervix.     This  result  might 


624  SYSTEM  OF  GYNECOLOGY 

have  been  easily  foretold ;  for  they  first  do  all  they  can  to  lower  the 
vitality  of  the  stump  by  ligaturing  and  separating  it  from  its  peritoneal 
covering,  and  then  they  shut  it  away  in  a  closed  space  without  drainage, 
or  any  possible  escape  for  discharge ;  unless,  indeed,  the  cervix  be  dilated 
and  forced  open  by  the  accumulation.  It  is  a  return  to  my  method  of 
January  1877,  except  that  I  did  not  shut  up  the  stump  by  sewing  over 
the  flaps.  Inflammation  shut  it  up  for  me  at  the  bottom  of  the  pelvis, 
and  then  the  accumulating  pus  forced  open  the  cervical  canal  with  a 
little  help  from  me,  the  pus  and  a  slough  were  discharged,  and  the  patient 
eventually  got  well ;  but  not  by  my  surgery.  Goffe  has  published  ten 
cases  operated  upon  on  this  method  by  himself  and  two  other  surgeons 
with  a  20  per  cent  mortality.  In  any  large  series  I  should  expect  it 
to  be  much  higher. 

Eastman  and  Chrobak  have  modified  Baer's  operation,  and  again,  I 
venture  to  think,  in  a  decidedly  retrograde  direction.  They  tie  the 
arteries  as  he  does,  cut  across  the  cervix,  and  then  burn  a  hole  through 
the  stump  into  the  vagina,  putting  a  gauze  drain  through  the  hole. 
Then  they  suture  the  cut  edges  of  the  peritoneum  so  as  to  shut  out  the 
stump.  This  is  really  making  an  extraperitoneal  operation,  of  somewhat 
similar  character  to  the  operation  of  Byford  to  be  next  described:  the 
same  objections  I  shall  have  to  raise  to  By  ford's  procedure  apply  also 
to  this;  practically  a  damaged  stump  is  extruded  into  the  vagina,  to 
suppurate,  and  most  probably  to  slough. 

ByfonVs  Operation.  —  In  1889  Henry  T.  Byford,  of  Chicago,  advo- 
cated the  carrying  of  the  stump  of  the  cervix  into  the  vagina,  through 
the  anterior  cul-de-sac,  by  separating  the  uterus  and  bladder.  After  the 
broad  ligaments  have  been  secured,  the  base  of  the  tumour  is  temporarily 
secured  by  an  elastic  ligature  and  pin.  The  uterus  and  tumour  having 
been  cut  away,  the  stump  is  ligatured  in  several  portions,  the  ligatures 
being  left  long ;  an  opening  is  then  made  into  the  vagina  behind  the 
bladder,  and  the  stump  is  carried  into  the  vagina  and  clamped  there,  the 
edge  of  the  peritoneum,  separated  with  the  bladder,  being  sewn  to  the  pos- 
terior surface  of  the  extruded  cervix  to  shut  off  the  peritoneal  cavity. 
Ancient  history,  indeed,  when  we  get  back  to  long  ligatures  and  a 
clamp  !  This  operation  courts  disaster  at  every  turn.  First  the  cervical 
stump  is  damaged  by  temporary  pin  and  elastic  ligature ;  then  its  vitality 
is  further  impaired  by  its  being  ligatured  in  several  pieces  ;  then  it  is 
twisted  out  of  its  natural  position  into  the  vagina ;  then  its  posterior 
surface  has  a  lot  of  sutures  passed  into  it  to  shut  off  the  peritoneum ; 
and,  finally,  it  is  clamped  in  the  vagina,  where,  with  its  long  ligatures 
and  septic  neighbourhood,  it  is  far  more  likely  to  slough  than  to  live. 
Mainert  suggested  cai'rying  the  stump  into  the  vagina  through  an 
opening  in  the  posterior  cul-de-sac  ;  another  modification  proposed  was 
dilatation  and  turning  the  cervix  inside  out,  an  operation  which,  I  imagine, 
is  easier  to  suggest  than  to  perform.  Another  equally  awkward  and 
dangerous  suggestion  was  to  cut  down  through  the  cervix  itself  into  the 
vagina,  and  then  to  invert  it.     All  these  operations  seem  to  me  equally 


HYSTERECTOMY  625 


vicious  in  principle,  and  only  vie  with  one  another  in  difficulty  of  per- 
formance. Kelly  of  Baltimore,  suspending  the  stump  in  the  abdominal 
cavity  by  long  ligatures,  also  made  a  retrograde  step  in  surgery.  If 
any  one  thing  delayed  the  progress  of  abdominal  surgery  more  than 
another  it  was  the  use  of  the  long  ligature.  To  find  it  turning  up 
again  is  astounding ! 

Polk's  Operation. — An  account  of  this  operation  was  published  by 
its  author,  AVilliam  M.  Polk  of  New  York,  in  the  Transactions  of  the 
American  Gyncecological  Society,  vol.  xvii.  1892,  p.  215 ;  and,  though  I 
believe  he  has  now  abandoned  it  in  favour  of  complete  extirpation,  it 
has  been  sufficiently  practised,  both  by  himself  and  others,  to  make  it 
desirable  that  it  should  be  described  in  this  article.  I  have  never 
practised  it  myself  because  I  was  not  favourably  iinpressed  either  by 
its  "  technique,"  or  by  its  results  as  seen  in  the  hands  of  Polk's  disci- 
ples in  this  country.  It  was  specially  introduced  for  that  most  formid- 
able class  of  cases,  to  which  I  have  already  referred,  in  which  a 
considerable  amount  of  enucleation  is  necessary  before  the  base  of  the 
tumour  can  be  reached  and  secured.  Heemorrhage,  septicaemia,  and  pro- 
longed suppuration  were  among  its  immediate  results,  as  I  saw  them  : 
and,  in  cases  which  recover,  hernia  on  a  large  scale  must  I  am  sure  be 
common  as  an  after  result.  He  separated  the  broad  ligaments,  round 
ligaments,  and  vessels  from  the  tumour ;  then  placed  a  rubber  ligature 
round  the  base  of  the  whole  mass  (this  would  be  cjuite  impossible  of  per- 
formance in  many  of  the  cases  in  which  I  have  operated)  ;  then  made  a 
circular  incision  all  round  and  stripped  down  the  j)eritoneal  covering, 
the  posterior  part  carrying  some  of  the  muscular  tissue  as  well ;  the 
uterus  and  tumour  were  amputated  within  this  sac,  and  all  the  visible 
vessels  ligatured ;  then  the  rubber  ligature  was  removed,  any  other  bleed- 
ing points  were  secured,  and  the  cut  surface  of  the  stump  was  seared  -o'ith 
the  actual  cautery,  which  was  also  passed  through  the  cervical  canal  into 
the  vagina.  The  edges  of  the  sac  were  then  sutured  to  the  edges  of  the 
opening  in  the  parietal  peritoneum  by  strong  catgut,  and  to  the  whole 
thickness  of  the  abdominal  incision  b}^  the  ordinar}^  abdominal  sutures ; 
the  opening  left  was  stuffed  with  iodoform  or  bichloride  gauze,  and  the 
whole  covered  with  an  ordinarv  dressing. 

Polk  is  a  strong  atlvocate  for  ligature  of  the  uterine  arteries  at  some 
distance  from  the  cervix  and  outside  the  ureters,  because  he  maintains 
that  in  this  situation  the  vessel  is  met  with  as  a  single  trunk,  and  haemor- 
rhage from  its  branches  is  avoided.  I  have  not  been  troubled  with 
hsemorrhage  in  the  few  cases  in  which  I  have  ligatured  the  uteriue 
arteries  close  to  the  cervix,  and  I  cannot  but  fear  for  the  ureters  by  Polk's 
method;  it  is  not  always  easy  to  isolate  the  artery  entirely  as  he 
advises.  A  study  of  his  own  diagram  emphasises  the  danger  to  the 
ureter,  and  shows  how  useless  it  is  to  ligature  the  branches  referred  to. 
He  advises  also  a  sort  of  chain  of  ligatures  in  tying  off  the  broad  ligaments. 
I  have  always  found  that  a  single  ligature  is  sufficient,  though  I  always 
transfix  with  a  double  silk  and  leave  one  loop  untied  in  case  of  any 


626  SYSTEM   OF  GYNECOLOGY 

emergency.  I  doubt  both  the  necessity,  and  the  advisability,  of  so  tying 
the  uterine  artery  as  to  secure  also  its  paravesical  and  vaginal  branches. 

The  difficulty  in  dealing  satisfactorily  with  the  cervical  stump  has  led 
many  operators  to  consider  whether  it  would  not  be  better  to  remove  the 
stump  entirely,  thus  performing  complete  extirpation  of  the  uterus.  I 
have  performed  this  operation  four  times ;  all  the  patients  made  excel- 
lent recoveries,  and  the  after  results  have  been  very  good.  I  have 
recently  examined  two  of  the  patients,  and  have  been  agreeably  sur- 
prised by  the  satisfactory  condition  of  the  vagina :  the  shortening  and 
shrinkage  is  not  nearly  so  marked  as  in  some  cases  in  which  the  cervical 
stump  has  been  left,  and  the  vaginal  vault  has  preserved  its  firmness  and 
shape ;  so  that  I  think  the  objection  to  the  operation  in  this  direction 
need  not  deter  us  from  its  performance  in  suitable  cases. 

I  will  briefly  describe  the  operation  as  I  perform  it,  and  then  refer 
to  the  modifications  now  practised  both  by  Eastman  of  Indianapolis,  and 
Chrobak  of  Vienna,  and  also  to  the  modifications  of  other  operators. 

Complete  Abdominal  Hysterectomy.  —  The  broad  ligaments  are 
ligatured  off  as  in  the  other  methods ;  if  it  be  desirable  to  leave  one 
ovary  this  can  readily  be  done  by  transfixing  and  tying  between  it  and 
the  uterus.  To  stop  back  bleeding  pressure  forceps  or  temporary  clamps 
are  applied  to  the  uterine  side  of  the  cut  broad  ligaments ;  the  anterior 
and  posterior  peritoneal  coverings  of  the  uterus  are  incised  and  peeled 
back,  fine  ligatures  or  pressure  forceps  being  applied  to  bleeding  points ; 
the  finger  is  then  pushed  down  between  the  tied  off  broad  ligaments  and 
the  side  of  the  uterus,  till  the  uterine  artery  is  felt  pulsating,  and  it  is 
then  ligatured  by  transfixion,  taking  care  to  keep  close  to  the  cervix  so  as 
to  avoid  the  ureter,  the  opposite  one  having  been  secured ;  the  vagina 
is  opened,  behind  the  l)ladder,  by  cutting  on  the  point  of  a  sound  pushed 
up  through  the  vagina  by  an  assistant ;  a  sponge  is  pushed  through  the 
opening  into  the  vagina  to  prevent  fluid  passing  from  it  into  the  peri- 
toneum ;  the  tumour  is  held  well  up  in  a  central  position  so  as  to  drag 
slightly  on  the  top  of  the  vagina,  and  then  the  point  of  a  long  pair  of 
scissors,  curved  on  the  flat,  is  run  quickly  round  the  top  of  the  vagina, 
the  tumour,  uterus,  and  cervix  are  lifted  away,  and  any  bleeding  points 
in  the  cut  edges  of  the  top  of  the  vagina  are  rapidly  secured  by  pressure 
forceps.  All  the  bleeding  points  are  then  secured  with  fine  carbolised 
silk,  either  by  simple  ligature  or  transfixion,  care  being  taken  to  draw  the 
edges  of  the  broad  ligament  and  divided  peritoneum  as  much  together  in 
this  process  as  possible,  so  as  to  reduce  the  size  of  the  opening  into  the 
vagina.  The  vagina  is  well  sponged  out  and  plugged  lightly  with  a  long 
strip  of  iodoform  gauze ;  a  Keith's  glass  tube  is  placed  in  the  pouch  of 
Douglas  so  that  any  blood  or  serum  running  back  into  this  pouch  from 
the  cut  edges  of  the  vagina  and  peritoneum  may  be  rapidly  removed,  and 
the  abdominal  incision  is  entirely  closed  round  the  drainage  tul)e :  this 
tube  is  only  left  in  for  24  or  48  hours,  by  which  time  oozing  has  ceased 
and  the  vaginal  i^lug  has  established  a  good  capillary  drain  from  the  top 


HYSTERECTOMY  627 


of  the  vagina  to  the  vulva ;  the  orifice  of  the  latter  is  kept  constantly 
dry  by  a  frequently  changed  plug  of  salicylic  wool,  or  other  dry  anti- 
septic absorbent  material.  For  the  first  few  days  the  urine  is  removed 
every  few  hours  by  the  catheter,  to  avoid  soakage  into  the  vaginal  plug. 
I  prefer  to  leave  this  plug  in  place  till  the  fifth  or  sixth  day,  if  the  con- 
dition of  the  patient  indicates  that  it  is  keeping  sweet,  as  it  acts  as  a 
valuable  support  to  the  upper  part  of  the  vagina  during  the  early  days 
of  healing,  and  is  a  good  capillary  drain ;  when  it  is  withdrawn  I  care- 
fully syringe  the  vagina  myself  with  an  antiseptic  douche  (usually  warm 
1  to  2000  corrosive  sublimate,  or  straw-coloured  iodine  and  water,  using 
the  latter  till  it  returns  without  losing  its  colour).  I  repeat  the  douche 
night  and  morning,  as  long  as  the  iodine-and-water  solution  is  decolorised, 
or  as  long  as  there  is  any  discharge.  I  never  put  any  fresh  plug  into 
the  vagina,  as  it  is  not  at  all  necessary,  and  I  think  the  manipulations 
necessary  for  its  introduction  are  a  source  of  danger. 

I  have  never  been  able  to  understand  the  great  trouble  taken  by  most 
abdominal  surgeons  to  shut  off  stumps  and  raw  surfaces  from  the  peri- 
toneum :  all  experience  shows  that  if  the  operation  be  aseptic,  effusions  of 
blood  are  much  more  rapidly  and  harmlessly  absorbed  by  the  peritoneum 
than  by  torn  and  cut  cellular  tissue ;  and  experience  likewise  teaches 
that  adhesions  to  any  raw  surface  left  free  in  the  peritoneum  are  very 
rare.  Damaged  suri?aces,  on  whicli  peritoneum  remains,  much  more 
frequently  adhere.  If  asepticity  be  not  quite  assured  it  is  easy  to  drain 
with  a  glass  tube.  In  my  opinion,  it  is  infinitely  more  dangerous  to 
shut  up  cut  and  torn  tissues  in  a  cavity  like  the  vagina. 

Bardenhauer  and  Eastman  deserve  the  chief  credit  for  the  perfection 
of  the  operation  of  complete  extirpation.  Chrobak,  a  close  follower  of 
Eastman,  has  also  been  most  successful  with  his  cases  of  complete  extir- 
pation. This  latter  operator  performed  the  operation  in  two  stages,  first, 
he  removed  the  uterus  and  tumours  as  in  ordinary  supravaginal  hyste- 
rectomy, and  then  he  removed  the  cervical  stump.  Early  in  1891  he 
reported  a  series  of  17  successful  cases  by  this  method ;  but  in  a  later 
paper  in  the  same  journal  (p.  713)  he  advocates  retention  of  the  cervix, 
ties  the  uterine  arteries,  dissects  off  peritoneal  flaps,  excises  the  tumour, 
burns  through  the  cervical  canal  with  Pacquelin's  cautery,  puts  a  gauze 
drain  through  into  the  vagina,  and  sutures  the  peritoneal  flaps. 

Polk,  Krug,  and  Edebohls  have  given  up  doing  the  operation  in  two 
steps,  and  they  remove  tumour,  uterus,  and  cervix  in  one  mass  much  in 
the  same  way  that  I  have  done ;  but  they  suture  the  opening  in  the 
peritoneum,  a  proceeding  which  I  believe  to  be  unnecessary.  Folk  has 
reported  18  cases  with  two  deaths,  and  Krug  18  cases  also  with  two 
deaths.  Zweifel  of  Leipzig  has  reported  51  cases  with  only  two  deaths. 
He  uses  a  chain  of  ligatures  all  interlocking,  silk  for  the  broad  ligaments 
and  catgut  for  the  cervix,  cuts  peritoneal  flaps  and  ligatures  inside  them, 
passes  Pacquelin's  cautery  through  the  cervical  canal  into  the  vagina, 
and  finally  sutures  his  peritoneal  flaps  together  so  as  to  shut  off  the 
field  of  operation  from  the  peritoneum. 


628  SYSTEM   OF  GYX^ECOLOGY 

French  and  Belgian  Surgery  and  Forcipressure. — Instead  of  using 
ligatures,  the  French  and  Belgian  surgeons  have  for  some  time  past  been 
using"  successfully  various  forms  of  forceps  for  clamping  the  broad  liga- 
ments. ]Mr.  Greig-Smith  in  this  country  some  years  ago  introduced  a 
vaginal  clamp  for  application  to  the  broad  ligaments  in  vaginal  hyste- 
rectomy, which  I  ventured  slightly  to  modify ;  but  I  am  not  aware  that 
it  has  been  much  vised.  In  the  hands  of  Eichelot,  Doyen,  Jacobs,  and 
others,  remarkable  success  has  been  obtained  in  the  removal  of  small 
fibroids  by  the  vagina  by  the  use  of  various  forceps.  Eichelot  has  had 
38  cases  with  only  one  death ;  Doyen,  22  with  one  death ;  and  Jacobs 
of  Brussels,  22  with  no  death.  These  results  compel  our  admiration 
for  the  surgical  skill  of  the  operators ;  but  in  this  country  we  have  not 
yet  become  convinced  of  the  necessity,  or  even  of  the  advisability,  of 
operating  at  all  upon  these  small  fibroids. 

Por  the  cure  of  moderate  sized  tumours  I  still  prefer  simple  removal 
of  the  ovaries  and  tubes ;  and  I  believe  that  the  patient  is  in  better  con- 
dition after  this  operation  than  after  a  total  extirpation  of  the  uterus  by 
the  vagina,  though  the  cure  may  be  less  showy.  I  am  sure  that  there  is 
something  faulty  in  the  methods  of  operation,  when  surgeons  do  not 
get  good  ultimate  results  from  this  operation ;  in  my  hands  the  results 
have  been  entirely  satisfactory,  and  I  am  constantly  seeing  old  patients 
whose  condition  thoroughly  bears  out  this  statement.  Before  pro- 
ceeding to  describe  this  operation,  I  will  summarise  the  various  methods 
of  performing  hysterectomy.  The  oldest  extraperitoneal  method  with  the 
wire  serre-noeud  of  Koeberle,  in  spite  of  all  that  has  been  and  can  be  said 
against  it,  still  is  probably  by  far  the  commonest  procedure.  The  elastic 
ligature  and  pin  never  seems  to  have  become  a  generally  favourite  method. 
Total  extirpation,  I  think,  now  comes  next ;  and  would,  I  think,  soon 
hold  the  field  alone,  if  the  difficulties  with  regard  to  the  roof  of  the 
pelvis,  and  the  damage  to  the  vagina,  could  be  satisfactorily  overcome. 

Of  the  intraperitoneal  methods,  that  of  Schroeder  is  practically  aban- 
doned on  account  of  its  mortality ;  Baer's  operation  is  certainly  the  most 
promising  of  these  methods.  Then  there  are  the  various  pressure  forceps 
and  clamps,  introduced  by  Richelot  and  others,  for  total  extirpation 
without  ligatures.  The  various  methods  for  extruding  the  stump  of  the 
cervix  into  the  vagina  are  procedures  which  I  venture  to  predict  will 
rapidly  disappear.  The  method  which  will  enal)le  the  surgeon  to  per- 
form an  absolutely  aseptic  operation  will  be  the  operation  of  the  future ; 
but  the  difficulties  are  so  great  that  it  has  not  yet  been  introduced,  and 
when  it  is  it  will  also  have  to  combine  with  asepticity,  a  sound  abdominal 
scar  and  a  practically  normal  vagina. 

It  is  evident  that  all  the  difficulties  of  the  operation  still  centre 
round  the  method  of  treating  the  stump ;  time  and  wider  experience 
alone  can  settle  wliich  mctliod  is  Ijcst. 

Removal  of  Ovaries  and  Tubes  for  Cure  of  Fibromyoma.  —  I  must  now 
describe  the  operation  for  the  removal  of  the  ovaries  and  tubes  (uterine 
appendages),  a  procedure  which,  in  a  certain  class  of  cases,  may  properly 


HYSTERECTOMY  629 

supplant  the  more  serious  mutilations  we  have  been  considering.  Before 
commencing  an  operation  for  uterine  fibromyoma,  I  always  tell  the  patient 
and  her  friends  that,  though  it  is  my  intention  to  remove  the  appendages 
or  to  perform  hysterectomy  as  the  case  may  be,  I  must  be  free  to  revise 
my  decision,  if  I  think  it  advisable  to  do  so,  after  I  have  opened  the 
abdomen ;  for  when  we  can  see  and  handle  the  parts,  we  find  cases  in 
which  the  one  operation  is  obviously  more  suitable  than  the  other. 
Removal  of  the  appendages  is  undoubtedly  the  proper  operation  to 
perform  in  those  cases  in  which  the  fibromyomas  though  small,  and  still 
confined  to  the  pelvis,  are  causing  serious  haemorrhage  or  serious  pain. 
Hysterectomy,  in  most  of  such  cases,  would  be  especially  difficult  and 
proportionately  dangerous ;  while  the  removal  of  the  appendages  may 
usually  be  accomplished  without  any  unusual  difficulty,  and  with  every 
prospect  of  a  cure,  immediate  as  regards  the  haemorrhage  or  pain,  and 
more  gradual  as  regards  the  disappearance  of  the  growths,  which  cause 
these  outward  symptoms.  Another  class  of  cases  for  which  removal  of 
the  appendages  may  often  be  substituted  for  hysterectomy,  is  that  in 
which  we  have  to  deal  with  a  moderate  sized  tumour,  involving  more  or 
less  of  one  uterine  wall ;  the  ovaries  being  still  separated  and  separable 
from  the  mass  by  manageable  pedicle ;  tumours  varying  in  size  from  that 
of  a  co3oa-nut  to  that  of  the  head  of  an  ordinary  child  of  ten  or  twelve. 
Such  cases  often  yield  very  good  results  from  this  operation,  the  tumour 
disappearing  quickly  after  it,  and  leaving  the  patient  in  very  good  and 
comfortable  condition.  If,  however,  in  such  a  case  the  ovaries,  or  one 
ovary,  are  found  sessile,  and  so  flattened  out  over  the  tumour  that  it 
is  difficult  to  tie  their  bases  without  fear  of  secondary  haemorrhage,  or 
without  leaving  some  portion  of  ovarian  tissue  behind,  it  is  far  better  to 
proceed  to  hysterectomy.  There  are  cases  which  are  equally  suitable  for 
either  procedure ;  then  we  may  be  guided  by  what  we  have  already  said 
to  the  patient,  or  by  her  probable  future :  thus  in  the  case  of  a  young 
married  woman,  or  of  one  who  is  going  to  marry,  it  may  be  advisable  to 
perform  hysterectomy  and  leave  an  ovary ;  whereas  in  a  woman  nearing 
the  menopause,  and  either  childless  or  unmarried,  it  may  be  better  to 
remove  the  ovaries.  The  need  for  a  quick  recovery  may  also  influence 
us  in  deciding  the  matter ;  recovery  after  hysterectomy  being  usually 
much  quicker  than  after  removal  of  the  appendages,  when  the  tumour 
is  left  to  be  gradually  absorbed.  Fibroc3''sts,  blood-cj'sts,  myxomatous 
or  cedematous  fibromyomas,  and  those  which  are  degenerating  rapidly 
(breaking  down),  are  not  suitable  cases  for  this  operation. 

There  caia  be  no  doubt  that  the  operation  of  removal  of  the  appendages, 
in  suitable  cases,  is  less  dangerous  to  life  than  that  of  hysterectomy,  and 
in  my  own  hands  its  after  results  have  been  excellent.  I  know  of  two 
cases  only  in  which  the  tumours  have  not  entirely  disappeared ;  and  one 
of  those,  for  reasons  too  long  to  enter  upon  here,  is  not  a  test  case :  the 
other  would,  I  believe,  have  recovered  if  she  had  given  herself  time,  but 
she  got  into  the  hands  of  the  electricians.  The  objections  to  the  opera- 
tion are  that,  in  order  to  obtain  a  perfect  result,  it  is  absolutely  necessary 


630  SYSTEM   OF  GYNECOLOGY 

to  remove  both  ovaries  entirely ;  and  that  in  many  cases  there  is  a  rather 
slow  convalescence,  one  which  may  extend  even  to  a  matter  of  years, 
before  the  tumour  is  entirely  absorbed,  and  the  pelvic  discomforts  of  its 
presence  entirely  gone ;  the  discomforts  incident  to  change  of  life,  too, 
are  usually  more  marked  after  this  operation  than  after  hysterectomy. 
When  it  has  been  decided  to  remove  the  appendages,  the  operation  is 
precisely  similar,  in  its  early  steps,  to  those  already  described.  After 
carefully  opening  the  abdomen  and  stopping  all  oozing  from  the  abdominal 
incision  by  pressure  forceps,  or  fine  carbolised  silk  ligatures,  the  ovaries 
and  tubes  are  sought  for  and,  if  found  to  be  sufficiently  free  from  the 
tumour,  are  tied  off  by  transfixion  just  as  in  ovariotomy  for  tumour.  I 
always  ligature  both  pedicles  securely  before  cutting  anything  away, 
because  the  necessary  manipulation  of  the  tumour  in  getting  hold  of  and 
ligaturing  the  second  set  of  appendages,  may  put  a  dangerous  strain  upon 
the  pedicle  already  tied;  for  these  pedicles  are  always  rather  short,  so 
that  not  much  of  a  stump  remains  on  the  distal  side  of  the  ligatures.  I 
am  always  careful  in  transfixion  to  puncture  through  the  utero-ovarian 
ligament,  if  this  be  possible ;  as  puncture  through  it  is  free  from  risk  of 
haemorrhage,  and  gives  a  firm  hold  for  the  ligatures  :  but  sometimes  the 
ligament  is  so  spread  out  over  the  surface  of  the  tumour,  that  it  is  almost 
impossible  to  transfix  it  without  risk  of  wounding  some  of  the  veins 
immediately  under  it ;  in  this  case  it  is  better  to  select  a  thin  and  blood- 
less bit  of  the  broad  ligament  for  puncture.  Puncture  of  a  vein  is,  in  my 
opinion,  the  great  risk  in  this  operation ;  even  in  ordinary  ovariotomy  it 
is  apt  to  lead  to  phlebitis,  but  in  the  latter  operation  it  is  generally  possible 
to  get  a  fresh  transfixion  behind  the  vein  puncture,  while  in  the  operation 
under  discussion  there  is  rarely  room  to  do  this,  and  one  has  to  leave  the 
silk  passing  through  the  vein  and  trust  to  control  the  oozing  by  another 
ligature  merely  tied  behind  it.  In  one  case  I  had  gangrene  of  the  leg 
from  phlebitis  following  puncture;  and  in  another  case,  though  the 
symptoms  were  somewhat  obscure,  I  always  myself  believed  that  some 
clot  and  trouble  in  the  pelvic  vein  led  to  the  death  of  the  patient.  I 
transfix  and  tie  both  pedicles ;  I  then  cut  away  both  ovaries  and  tubes, 
and  then  apply  a  third  Xo.  2  carbolised  Chinese  twist  ligature  round  the 
whole  of  each  pedicle.  I  always  sponge  out  the  pelvis,  too,  before  com- 
pleting the  ligature.  It  is  rarely  necessary  to  drain  in  these  cases,  which 
is  fortunate,  for  it  is  very  difficult  to  get  the  glass  tube  to  lie  nicely 
behind  the  tumour  without  bringing  it  out  so  high  in  the  incision  that 
it  lies  awkwardly  among  the  intestines  and  is  apt  to  irritate  them. 

Hysterectomy  for  Procidentia. — This  operation  I  have  never  per- 
formed. 1  have  never  seen  a  case  which  seemed  to  me  to  justify  so 
extreme  a  proceeding ;  indeed,  I  have  never  myself  met  with  a  case  in 
which  the  uterus  could  not  be  kept  up,  so  as  to  make  the  patient  com- 
fortable, by  some  form  of  vaginal  support.  I  can  understand,  however, 
that  some  patients  would  rather  run  the  risk  of  operation,  than  have  the 
constant  trouble  and  annoyance  of  a  support.  The  removal  of  the  uterus 
should  in  such  a  case  Ije  performed  through  the  vagina;  and  as  I  have  not 


HYSTERECTOMY  631 


had  occasion  to  refer  to  kolpo-hysterectomy,  I  will  briefly  describe  the 
method  I  prefer.  Kolpo-hysterectomy  for  malignant  disease  is,  I  under- 
stand, included  in  the  article  on  ''  Cancer  of  the  Uterus,"  and  does  not 
fall  Avithin  my  province. 

Kolpo-Hysterectomy.  —  For  some  days  before  the  performance  of  this 
operation  the  patient  should  be  prepared  by  frequent  large  anti- 
douches.  I  think  it  is  best  to  vary  them,  using  in  turn  1  to  60 
carbolic  acid,  1  to  1000  corrosive  sublimate,  and  iodine  and  water  of 
deep  straw  colour.  I  always  begin  the  preparation  by  thoroughly 
cleansing  the  uterine  cavity  with  tr.  of  iodine  applied  on  cotton  wool  by 
means  of  a  Playfair's  probe,  and,  if  possible,  a  free  washing  out  with 
iodine  and  water  through  a  double  action  tube.  For  the  forty-eight 
hours  preceding  the  operation  the  vagina  should  be  washed  out 
thoroughly,  every  six  hours,  with  a  full  douche  of  one  or  other  of  the 
antiseptic  solutions  named  above.  The  last  douche  is  to  be  given  just 
before  the  patient  is  placed  on  the  operating  table. 

The  vulva  should  be  thoroughly  washed  with  carbolic  soap  night  and 
morning  for  some  days  before  the  operation,  and  again  Avhen  the  last 
douche  is  given ;  especial  attention  being  given  to  the  folds  between  the 
thighs  and  inside  the  labia,  and  between  the  latter  and  the  clitoris.  I 
always  shave  off  what  hair  I  wish  to  be  removed  after  the  patient  is 
under  chloroform,  as  it  only  takes  a  few  seconds,  and  is  a  very  disa- 
greeable proceeding  if  done  during  consciousness.  The  patient  should  be 
placed  on  her  back  with  head  and  shoulders  low,  and  the  legs  supported 
in  the  lithotomy  position  by  Clover's  crutch.  The  operator  should  sit 
at  the  foot  of  the  table,  with  his  back  to  a  window.  A  strip  of  iodoform 
gauze  is  passed  into  the  uterus  so  as  to  block  the  cervical  canal,  and 
the  cervix  is  seized  by  a  strong  locking  volsella  with  curved  handles, 
so  that  an  assistant  can  move  the  uterus  about  freely,  as  directed,  with 
as  little  obstruction  to  the  vaginal  outlet  as  possible.  The  operator 
pulls  the  uterus  well  down  to  the  outlet,  and  then  hands  it  to  the  assist- 
ant, who  moves  it  backwards  and  forwards  and  from  side  to  side  as 
required  during  the  subsequent  steps  of  the  operation. 

The  operator  now  divides  the  mucous  membrane  all  round  the  cervix, 
as  high  up  as  the  vaginal  reflexion  will  admit,  taking  care  to  make  only 
a  superficial  division  at  the  sides  over  the  vessels,  and  cutting  well 
through  into  the  cellular  tissue  in  front  and  behind.  He  then  pushes 
back  the  mucous  membrane  towards  the  bladder,  and  towards  the  pouch  of 
Douglas,  till  the  sense  of  resistance  warns  him  that  the  limit  of  safety  is 
reached.  Then  he  either  pushes  his  finger  through  into  the  pouch  of  Doug- 
las, or  perforates  it  with  Lister's  sinus  forceps,  expanding  the  blades  as 
they  are  withdrawn  to  allow  the  finger  to  pass  in.  The  peritoneum  is  then 
divided  right  across  the  back  of  the  pouch,  and  next  between  the  bladder 
and  uterus,  the  puncture  and  section  here  being  aided  by  the  finger  hooked 
over  the  fundus.  A  large  carbolised  sponge  is  now  pushed  into  the  lower 
part  of  the  peritoneum  to  keep  back  the  intestines  and  omentum,  and  pre- 
vent any  fluid  or  air  from  the  vagina  being  sucked  into  that  cavity ;  and 


632  SYSTEM  OF  GYNECOLOGY 

the  securing  and  separating  of  tlie  broad  ligaments  is  tlien  undertaken. 
Different  operators  differ  greatly  in  their  method  of  performing  this 
part  of  the  operation.  I  prefer  to  snip  the  ligaments  gradually  through 
^vith  scissors,  keeping  the  blades  close  to  the  sides  of  the  cervix,  and 
seizing  and  tying  each  bleeding  point,  generally  by  passing  a  fine  silk 
under  the  open  mouth  of  the  vessel,  a  much  slower  proceeding  than 
many  of  those  employed,  but  one  having  the  merit  of  being  very  sure. 
The  operator  is  absolutely  free  from  risk  of  secondary  hsemorrhage ;  he 
does  not  leave  great  pieces  of  tied  tissue  to  suppurate  or  slough  ;  and  he 
sees  exactly  at  each  step  Avhether  the  tissue  cut  through  be  normal  or 
infiltrated.  If  the  uterus  is  firmly  dragged  down  and  over  to  the  side 
opposite  to  the  one  being  divided,  the  trouble  from  back  bleeding  from 
the  uterus  is  but  little ;  but  if  there  be  any,  it  is  easily  checked  by  the 
application  of  a  slender  clamp,  or  long,  thin-bladed  forceps.  When  both 
sides  have  been  divided  the  uterus  is  drawn  down  and  removed,  the 
spongers  removed  from  the  pouch  of  Douglas,  the  vagina  is  packed  up 
lightly  to  the  circular  incision  at  the  top  with  iodoform  gauze,  care  being 
taken  not  to  make  this  packing  separate  the  edges  of  the  wound,  and  a 
sanitary  towel,  fastened  on  by  a  T  bandage,  completes  the  dressing.  The 
sanitary  towel  should  be  frequently  changed.  The  vaginal  plug  can  in 
most  cases  be  safely  left  for  five  days  to  a  week,  when  it  is  gently  with- 
drawn, and  the  vagina  carefully  douched  with  iodine  and  water.  I 
always  do  this  myself  night  and  morning  for  the  first  week  after  the 
removal  of  the  plug.  I  never  use  any  sutures  to  bring  the  edges  of  the 
divided  peritoneum  together,  and  I  find  that  if  the  plugging  is  lightly 
and  properly  done,  it  gives  just  the  necessary  support,  the  edges  fall 
naturally  together,  there  is  no  fear  of  intestinal  prolapse,  and  drainage 
into  the  plug,  and  through  it,  is  free  and  efficient.  I  always  have  tlie 
catheter  used  while  the  plug  remains  in,  to  avoid  wetting  it  with  urine. 
In  performing  this  operation  for  procidentia,  it  is  necessary  to  remem- 
ber that  the  bladder  and  ureters,  and  even  the  intestines,  are  very  apt 
to  be  much  displaced,  so  that  much  greater  care  is  required  in  the  catting 
parts  of  the  operation.  In  such  cases  the  method  I  employ  is  especially 
likely  to  avoid  injury  to  these  displaced  organs. 

I  sometimes  ligature  the  uterine  arteries  by  transfixion  before  com- 
mencing the  gradual  division  of  the  broad  ligaments.  This  is  not  always 
easy  to  do,  but,  if  it  can  be  done,  it  undoubtedly  saves  haemorrhage,  and 
renders  the  rest  of  the  operation  easier.  Some  operators  transfix  and 
tie  the  broad  ligaments  on  each  side  in  a  mass ;  others  do  this  after  invert- 
ing the  uterus  into  the  vagina;  others  bisect  the  organ  and  remove  it  in 
two  halves.  The  French  and  Belgian  surgeons  have  been  obtaining  the 
most  brilliant  results  })y  the  use  of  pressure  forceps  applied  up  each  side 
of  the  uterus,  left  on  the  l)road  ligaments  for  some  hours,  and  then  care- 
fully removed.  The  time  during  which  it  is  necessaiy  to  leave  them  on 
has  been  gradually  reduced  till,  I  believe,  some  operators  think  twelve 
hours  long  enough.  Of  course  the  sooner  they  can  be  removed  with 
safety,  so  far  as  fear  of  haemorrhage  is  concerned,  the  less  the  risk  of 


HYSTERECTOMY  633 


sloughing  of  the  tissues  crushed  between  their  blades.  This  unfortunate 
result  of  their  use,  which  must  happen  to  some  extent  in  all  cases,  has  led 
to  septicaemia  in  not  a  few.  This  is  to  me  the  great  objection  to  their  use. 
As  I  have  already  said,  Mr.  Greig-Smith,  several  years  ago,  introduced  a 
very  efficient  little  clamp  for  securing  the  broad  ligaments,  in  which  I 
ventured  to  make  some  slight  modification,  but  I  have  never  used  it  on 
the  living  subject,  and  I  think  if  I  ever  do  adopt  this  method  I  shall 
prefer  to  use  some  of  the  forceps  now  in  use  in  France.  Richelot's  seem 
admirably  adapted  for  their  Avork,  and  his  brilliant  success  bears  witness 
to  their  excellence. 

Hysterectomy  for  Intractable  Inversion.  —  It  is  very  rarely  that  some 
of  the  excellent  repositors  which  have  been  invented  will  not  reduce 
an  inverted  uterus  ;  but  now  and  then  a  case  has  been  overlooked  and  left 
so  long  untreated  that  abnormally  related  parts  have  grown  firmly  to- 
gether, and  nothing  is  left  but  to  remove  the  organ.  Formerly  it  was 
thought  sufficient  to  amputate  the  mass  with  an  ecraseur,  and  I  have  my- 
self successfully  performed  this  operation.  It  is,  however,  a  most  un- 
scientific procedure,  and  has  in  several  cases  ended  in  serious  disaster  — 
a  coil  of  intestines  or  other  important  organ  having  become  involved  in 
the  amputation. 

Tlie  diar/nosis  of  complete  inversion  should  not  be  difficult;  com- 
bined examination,  with  aid  of  an  anaesthetic  if  necessary,  will  soon  show 
the  presence  or  absence  of  the  uterine  body  in  its  proper  place  in  the 
pelvis  or  abdomen.  The  finger  in  the  rectum  will  recognise  the  depres- 
sion in  place  of  the  uterine  body ;  in  the  vagina  the  absence  of  the  os 
uteri,  and  possibly  the  detection  of  the  openings  of  the  Fallopian  tubes, 
will  render  the  diagnosis  absolute.  It  may  occasionally  be  a  little  diffi- 
cult at  first  to  diagnose  between  inversion  and  a  large  polypus,  but 
attention  to  the  above  points  should  prevent  error.  If  both  conditions 
should  be  present,  the  polypi  having  led  to  inversion,  then  greater  care 
may  be  necessary  to  avoid  unintentionally  including  the  uterine  body  in 
the  operation  for  removal  of  the  polypus. 

Immediate  removal  by  cutting,  with  ligature  of  the  divided  vessels 
by  the  ecraseur  or  the  cautery,  were  the  methods  formerly  used,  and 
with  a  terrible  mortality.  Gradual  removal  by  compression,  as  may  be 
supposed,  was  not  much  more  successful,  though  the  elastic  ligature 
certainly  reduced  the  mortality  considerably. 

The  method  of  first  compressing  the  mass  with  an  encircling  ligature, 
so  as  to  produce  adhesions  between  the  abnormally  opposed  serous  sur- 
faces, and  then  amputating  below  the  constriction,  very  considerably 
reduced  the  mortality,  but  it  still  remained  over  15  per  cent.  There  can 
be  no  reason  why  complete  excision,  carefully  performed  on  the  lines  laid 
down  for  excision  in  procidentia,  should  not  be  attended  Avith  good 
results;  but  it  would  be  necessary  to  bear  in  mind  the  changed  relation 
of  parts  brought  about  by  the  inversion,  and  to  modify  the  exact  details 
of  the  procedure  accordingly. 

Operations  on  the  Gravid  Uterus.  —  I  now  pass  to  the  consideration 


634  SYSTEM  OF  GYjV^COLOGY 

of  the  various  operations  -n-liicli  have  been  suggested  for  dealing  with  the 
gravid  uterus,  when  the  natural  passages,  either  from  deformity  of  the 
bones  of  the  pelvis,  or  from  the  presence  of  a  neoplasm,  do  not  admit  of 
the  delivery  of  a  living  child. 

I  think  it  is  beyond  the  scope  of  my  article  to  deal  with  symphysiotomy, 
peh'iotomy,  and iJiibiotomy.  The  cases  in  which  these  methods  would  be 
employed  must  be  very  unusual,  when  we  have  such  a  range  of  successful 
procedures  as  the  improved  Caesarean  section,  Porro's  operation,  and 
complete  extirpation  to  choose  from. 

Regional  Anatomy  of  the  Pelvis  at  Term.  —  Polk  and  Greig-Smith,  by 
their  careful  dissections,  have  thrown  valuable  light  upon  the  changes 
brought  about  in  the  regional  anatomy  of  the  pelvis  by  pregnancy,  espe- 
cially in  the  relations  of  the  peritoneiun,  the  ovarian  and  the  uterine  ar- 
teries, the  uterine  ligaments,  and  the  ureters. 

Briefly  these  changes  are,  elevation  of  the  pelvic  peritoneum,  with 
great  laxity  of  the  underlying  cellular  tissue ;  the  broad  ligaments  be- 
come abdominal  instead  of  pelvic,  and  triangular  in  form  instead  of  quad- 
rangular ;  their  layers  are  separated  and  more  loosely  attached.  The 
arteries  are  much  enlarged,  especially  the  ovarian ;  the  uterine  artery  is 
elevated  so  that  it  is  in  part  removed  from  the  uterine  wall ;  its  relations 
to  the  ureter  remain  much  the  same.  The  ureters  are  elevated  along 
with  the  bladder  and  vagina,  and  lie  very  close  to  the  latter  along  its 
antero-lateral  surfaces.  At  the  end  of  the  hrst  stage  of  labour  the  ureter 
crosses  the  line  of  the  os  uteri  obliquely  at  the  juncture  of  the  anterior 
and  middle  third ;  and,  at  the  level  of  the  external  os,  the  space  between 
the  ureter  and  rectum  is  twice  as  great  as  the  space  between  the  ureter 
and  bladder. 

Cresarean  section  would,  I  suppose,  hardly  come  under  hysterectomy 
and  allied  operations ;  but  as  it  is  one  of  the  steps  in  the  other  two 
operations,  I  shall  briefly  consider  its  performance. 

The  terrible  mortality  of  the  old  Caesarean  section  led  to  the  equally 
sad  destruction  of  infant  life  by  craniotomy  and  other  barbarous  proceed- 
ings ;  but  now  with  the  splendid  achievements  of  abdominal  surgery  all 
these  horrors  are  passing  away,  and  we  have  only  to  consider  which 
surgical  procedure  is  most  suitable  to  the  particular  case,  and  how  best 
so  to  perfect  the  procedure  as  to  save  the  lives  of  the  largest  number 
of  mothers  and  children.  The  surgeon  who  decides  upon  performing 
Csesarean  section  should  always  be  prepared  with  the  instruments 
necessary  for  proceeding  to  Porro,  or  to  complete  hysterectomy;  if 
circumstances  arise  which  render  either  of  these  procedures  necessary. 

The  improved  Cmsarean  section  owes  its  present  success  chiefly  to  the 
German  surgeons,  especially  to  Sllnger  and  Leopold.  The  former  first 
suggested  the  improved  method  of  suturing  the  uterus,  and  the  latter 
was  the  first  surgetjn  to  carry  it  out  successfully.  Many  small  details 
which  contribute  to  success,  and  require  care,  will  1)0  duly  noted  in 
describing  the  operation ;  but  the  detail  which  has  brought  about  such 
an  astonishiu''  difference  in  results  between  the  old  and  the  new  Csesarean 


HYSTERECTOMY  635 


section  is  the  method  of  closing  the  uterine  wound.  Another  most 
important  element  in  the  recent  success  is  the  performance  of  the  opera- 
tion at  an  appointed  and  carefully  selected  time  —  not  during  the  first 
stage  of  labour,  but,  as  in  any  other  abdominal  operation,  after  due  and 
careful  examination  and  consideration  of  all  the  conditions,  and,  more 
important  still,  after  due  and  careful  preparation  of  the  patient.  Thus 
everytliing  is  carried  out  in  order  and  without  hurry  or  excitement, 
conditions  which  so  frequently  brought  disaster  in  the  old  operation. 
Another  great  advantage  of  the  "  elective  operation  "  is  that  it  need  no 
longer  be  performed  by  the  inexperienced  family  doctor,  but  by  the  trained 
and  experienced  abdominal  surgeon;  and  I  maintain  that  there  is  no 
great  operation  of  surgery  which  so  clearly  demands  that  its  performance 
should  be  placed  in  the  hands  of  the  experienced  operator.  When  it  was 
thought  not  advisable  to  operate  until  labour  had  commenced,  such  an 
arrangement  was  often  impossible,  but  now  the  patient  can  be  carefully 
prepared  and  placed  in  some  apartment  suitable  for  operation  ;  she  should 
also  have  the  benefit  of  skilled  surgery.  The  preparation  of  the  patient 
should  be  precisely  the  same  as  for  any  other  abdominal  operation ;  the 
vagina  and  external  genitals  should  be  carefully  cleansed  some  days 
beforehand.  Then,  just  before  the  operation,  the  surgeon  should  exam- 
ine the  cervix,  and  satisfy  himself  that  it  is  patent,  and  will  allow  of 
proper  vaginal  drainage,  and  also  examine  the  uterus  and  see  that  it 
contracts  properly. 

Ope)xition.  —  The  abdominal  incision  should  be  from  5  to  6  inches 
long.  It  should  commence  above  and  to  the  left  of  the  navel,  and  be 
carried  down  only  to  a  point  about  2i  inches  above  the  pubes  —  the 
elevation  of  the  peritoneum  between  the  uterus  and  bladder  will  place 
the  latter  organ  in  danger  if  it  be  carried  lower.  As  soon  as  the  uterus 
is  exposed,  the  assistant  standing  opposite  to  the  operator  should  place 
his  hands  deep  in  the  flanks  and  under  the  uterus  on  each  side,  so  that 
he  can  press  it  forward  into  the  incision,  making  it  slightly  bulge  through 
it.  Then  a  large  flat  sponge  is  placed  between  the  uterus  and  the  anterior 
parietes  on  each  side.  If  the  assistant  attends  quietly  and  carefully  to 
his  work  all  through  the  operation,  always  keejiiug  the  uterus  well  pressed 
up  against  the  anterior  parietal  peritoneum,  no  fouling  of  the  peritoneum 
is  possible  ;  but  if  I  had  to  i^erform  the  operation  without  an  assistant 
upon  whom  I  could  rely  for  this  help,  I  should  substitute  the  long  in- 
cision, and  turn  the  uterus  out  of  the  abdomen  before  incising  it. 

The  incision  into  the  uterine  wall  is  made  vertically,  beginning  well 
up  at  the  top  of  the  abdominal  incision,  and  not  carried  too  low,  for  fear 
of  wounding  branches  of  the  uterine  artery. 

If  the  haemorrhage  be  very  severe,  a  fcAv  pairs  of  my  T-shaped  forceps 
may  be  rajndl}'  ai)plied  to  the  edges  of  the  cut,  but  if  the  use  of  forceps 
can  be  avoided  it  is  better,  as  all  traumatism  is  bad.  The  operator  then 
seizes  the  child  by  the  head  and  rapidly  extracts  it.  Should  the  feet 
present  he  may  extract  by  them ;  but  in  this  case  care  is  required  lest 
the  uterine  wound  close  tightly  round  the  child's  neck.     If  this  should 


636  SYSTEM  OF  GYNMCOLOGY 

happen  it  must  be  freed  at  once  by  enlarging  the  wound  in'  an  upward 
direction,  lest  it  be  torn  down  into  the  lower  segment  of  the  uterus. 
The  cord  should  then  be  rapidly  divided  between  two  pairs  of  forceps,,  or 
two  ligatures  which  can  be  almost  as  quickly  applied,  and  the  child 
handed  to  an  assistant  or  niirse.  A  hypodermic  injection  of  ergotine 
should  then  be  given,  and,  if  the  mother's  condition  allow  it,  a  short 
pause  be  made  to  allow  of  natural  separation  of  the  placenta.  If  this 
do  not  occur,  and  blood  is  being  lost,  the  placenta  must  be  peeled  off  and 
extracted,  the  uterine  cavity  thoroughly  cleared  of  the  secundines,  and 
a  strip  of  iodoform  gauze  passed  through  the  cervix  to  act  as  a  drain. 

Closure  of  the  Uterine  Wound. — The  all-important  step  in  the  opera- 
tion has  now  to  be  carried  out,  and  the  uterine  Avound  closed  by  Sanger's 
suture.  First  a  row  of  deep  silk  sutures  (ISTo.  2  Chinese  twist)  is  placed ; 
each  suture  enters  the  peritoneum  about  half  an  inch  from  the  edge  of 
the  wound,  slants  obliquely  through,  and  is  brought  out  in  the  muscular 
wall  some  little  distance  from  the  uterine  cavity.  These  sutures  are 
three-quarters  of  an  inch  apart,  and  the  uppermost  and  lowermost  ones 
should  be  placed  well  beyond  the  limits  of  the  incision  ;  then  a  second 
row  is  placed,  two  sutures  between  each  of  the  deep  ones,  the  needle  enters 
the  peritoneum  a  little  nearer  its  cut  edge  than  for  the  previous  ones,  and 
comes  out  more  superficially  in  the  uterine  wall ;  then  it  is  carried  up 
and  through  the  cut  edge  of  the  peritoneum  on  its  own  side,  then  through 
the  cut  edge  of  the  peritoneum  opposite  side  of  the  incision,  and  through 
the  cut  edge  of  the  uterine  wall  about  its  centre,  and  out  obliquely 
through  the  peritoneum ;  this  row  of  sutures  is  also  carried  beyond  the 
9nds  of  the  incision.  When  all  are  in  place  the  superficial  ones  are  tied 
first,  and  these  will  invert  both  edges  of  peritoneum  ;  then  the  deep  ones 
are  tied,  and  these  bring  the  serous  surfaces  firmly  together,  almost  bury- 
ing the  superficial  sutures.  Should  the  apposition  of  the  serous  surfaces 
still  not  appear  close  enough  all  along  the  line,  a  fine  continuous  super- 
ficial suture  may  be  applied  to  make  everything  still  more  secure.  The 
essence  of  the  method  is  not  to  let  any  of  the  sutures  come  near  the  in- 
terior of  the  uterus,  and  to  bring  two  good  broad  strips  of  inverted 
peritoneum  firmly  into  contact  all  the  way  along  the  incision.  If  the 
assistant  has  done  his  work  well  by  keeping  the  iiterus  well  against  the 
parietes  there  will  be  no  need  to  sponge  out  the  peritoneum ;  all  that 
is  necessary  will  ])e  to  remove  the  flat  sponges,  and  close  the  external 
incision. 

If  it  be  desirable  to  prevent  the  possibility  of  future  pregnancies,  the 
tubes  on  each  side  should  be  ligatured  in  two  places  with  fine  silk,  and  a 
small  V-sha])f'd  ])ortion  removed. 

If  any  drainage  is  desired  a  small  rubber  tube  may  be  placed  in  the 
anterior  cnl-de-.sac,  and  sutured  into  the  lower  angle  of  tlie  abdominal 
wound. 

If  the  uterus  contracts  properly  the  case  will  probably  do  well,  often 
as  well  as  after  an  ordinary  confinement;  but  if,  before  the  abdominal 
incision  is  closed,  the  uterus  is  seen  not  to  be  contracting  properly,  then 


HYSTERECTOMY  637 


it  may  become  a  question  whether  it  is  not  better  to  perform  Porro's 
operation,  or  a  complete  extirpation  of  the  uterus  immediately. 

The  literature  of  the  subject  of  Csesareau  section  is  now  so  very 
large,  that  I  have  avoided  going  into  the  history  of  the  operation,  or 
attempting  to  deal  with  the  suggestions  good,  bad,  and  indifferent,  which 
have  been  made  concerning  its  method  of  performance ;  I  have  contented 
myself  with  describing,  as  clearly  as  I  can  with  our  present  knowledge, 
the  way  in  which  I  think  it  should  be  performed. 

The  only  point  which  perhaps  deserves  notice  to  which  I  have  not 
alluded,  is  the  question  of  applying  temporary  intraperitoneal  elastic 
compression  round  the  uterus,  at  the  level  of  the  internal  os,  during  the 
incision  of  the  uterus  and  the  extraction  of  the  child.  I  do  not  think  it 
is  necessary  in  ordinary  cases,  but  if  alarming  haemorrhage  occur  a  loop 
of  elastic  tube  can  be  rapidly  passed  round  and  tightened,  and  its 
crossed  ends  secured  in  a  pair  of  Wells'  large  pressure  forceps.  The 
objections  to  its  use  are  that  it  adds  another  element  of  risk  in  the 
traumatism  produced  at  its  site,  and,  if  the  operation  be  at  all  prolonged, 
that  it  asphyxiates  the  child.  I  think,  however,  it  may  be  worth  while 
always  to  place  a  rubber  tube  in  position  round  the  neck  of  the  uterus 
before  incising  it,  so  that  if  necessity  arise  it  can  be  quickly  tightened. 
If  it  has  to  be  applied  at  an  urgent  moment  valuable  time  Avill  be  lost, 
and  the  peritoneum  will  be  fouled  with  blood,  and  very  likely  with 
uterine  contents  also. 

The  after  treatment  is  the  same  as  for  any  other  abdominal  opera- 
tion, with  the  addition  of  attention  to  the  condition  of  the  mammae,  and 
warm  antiseptic  vaginal  douches  every  six  or  eight  hours.  The  cervical 
drain  will  in  most  cases  gradually  come  away  by  itself;  but  if  it  do  not, 
it  can  be  gently  Avithdrawn  in  about  forty-eight  hours. 

Porro's  operation,  first  planned  and  successfully  performed  in  1876 
by  the  Italian  surgeon  whose  name  it  bears,  was  suggested  to  him  by 
the  success  of  extraperitoneal  supravaginal  h3^sterectom3',  and  is  a  com- 
bination of  Caesarean  section  with  this  latter  operation.  Some  250  cases 
of  this  operation  have  now  been  recorded,  with  a  maternal  mortality 
of  about  50  per  cent.  Utero-ovarian  amputations  performed  during 
pregnancy,  but  before  the  foetus  is  viable,  have  also  been  spoken  of, 
improperly,  as  Porro's. 

One  of  the  advantages  claimed  originally  by  Porro  for  the  operation 
was  that  it  would  save  more  mothers  than  Cesarean  section ;  probably 
this  was  true  then,  with  the  old  Csesarean  section  in  vogue ;  but  with 
the  improved  and  ''  elective  "  Caesarean  section  I  doubt  if  the  claim  still 
holds  good. 

Another  great  advantage  claimed  was  that  the  operator  could  select 
his  own  time,  and  properly  prepare  the  patient ;  this  advantage  now 
belongs  likewise  to  C'i^tsarean  section. 

The  patient  should  be  prepared  in  exactly  the  same  way  as  before 
hysterectomy  for  tumour;  that  is,  the  bowels  should  be  well  cleared,  the 
bladder  emptied,  and  the  vagina  and  vulva  well  cleansed  hj  antiseptic 


638  SYSTEM   OF  GYNECOLOGY 

douche,  -washing,  and  shaving.  Any  time  near  the  time  of  natural 
delivery  will  suit  quite  well  for  the  operation,  which,  up  to  the  time  of 
full  exposure  of  the  pregnant  uterus,  is  performed  in  exactly  the  same 
way  as  for  tumour.  When  this  point  is  reached  the  site  of  the  placenta 
should,  if  possible,  be  made  out  in  order  that  this  organ  may  be  avoided 
in  opening  into  the  uterus ;  this  discovery  is,  however,  rarely  possible, 
and  more  stress  has  been  laid  on  its  importance  than  I  think  it  deserves. 
A  trustworthy  assistant  should  then  grasp  the  uterus  and  broad  ligaments 
at  the  lowest  point  which  he  can  reach  with  his  hand  in  the  pelvis,  so  as 
to  be  ready  at  once  to  arrest  the  cird^ilation  when  the  uterus  is  opened ; 
but  he  should  not  interfere  by  closing  his  hand  until  the  operator  is 
actually  beginning  to  incise  the  uterine  wall ;  thus  the  child's  blood- 
supply  is  not  interfered  with  till  the  last  moment.  A  rubber  tube 
may  also  be  put  loosely  round  the  cervix,  as  advised  in  the  previous 
operation,  to  be  secured  if  necessary.  The  operator,  avoiding  the 
placental  site,  if  this  be  possible,  makes  a  small  incision  through  the 
uterine  wall  and  then  completes  the  opening  by  tearing  with  his  fingers 
(a  modification  originally  suggested  by  myself  when  assisting  Dr.  Godson 
to  perform  the  operation) ;  the  child  is  then  at  once  extracted  and  handed 
to  an  assistant,  who  ties  and  divides  the  cord,  and  gives  the  necessary 
attention  to  the  child.  The  uterus  should  be  packed  round  with  carbolised 
sponges  during  incision  and  removal  of  the  child ;  and  when  the  latter 
part  of  the  procedure  is  accomplished,  the  opening  into  the  uterus  should 
be  plugged  at  once  with  a  large  sponge  or  sponges,  the  surrounding 
sponges  quickly  removed,  and  Koeberle's  serre-noeud  applied  round  the 
base  of  the  uterus  and  the  broad  ligaments,,  just  above  the  hand  of  the 
assistant,  who  has  been  preventing  haemorrhage  by  firmly  grasping  it  as 
already  mentioned.  If  it  be  thought  advisable  to  leave  one  ovary,  it  can 
readily  be  excluded  from  the  wire  at  this  stage,  either  with  or  without 
its  tube;  and  this  I  strongly  advise  in  all  cases  in  which  the  woman 
operated  upon  is  married  and  young.  As  soon  as  the  wire  is  fixed  and 
screwed  up  the  assistant  withdraws  his  hand,  the  pin  is  passed  through 
the  uterus  immediately  above  the  wire,  and  the  uterus  is  cut  away,  great 
care  being  taken  to  pack  it  well  round  again  with  carbolised  sponges,  and 
to  prevent  any  escape  of  its  contents  into  the  peritoneum.  If  there 
appear  to  be  any  necessity  for  draining  the  peritoneum,  a  Keith's  glass 
tube  is  placed  in  the  pouch  of  Douglas,  as  soon  as  the  peritoneum  has 
been  sponged  out,  and  the  wound  closed  round  it  by  the  usual  silk 
sutures ;  drainage  is,  however,  rarely  necessary  in  these  cases,  and  is  to 
be  avoided  if  possible,  for  the  reasons  already  given  in  describing  the 
operation  as  performed  for  fibromyoma.  Dry  gauze  dressing  is  packed 
round  the  stump,  which  is  then  carefully  treated  with  solid  perchloride 
of  iron ;  more  gauze,  held  by  big,  broad,  supporting  bands  of  adhesive 
plaster  and  covered  by  a  towel  pad,  and  an  abdominal  Itinder  secured 
by  three  safety  pins,  complete  the  y^rocedure.  The  after  treatment  is 
precisely  the  same  as  after  the  operations  already  described,  except  in 
so  far  as  it  may  be  modified  by  any  degree  of  milk  fever.     A  free  and 


HYSTERECTOMY  639 


early  application  of  extract  of  belladonna  and  glycerine  covered  with 
cotton  wool  and  oil  silk,  repeated  every  twelve  hours,  is  the  most  effi- 
cient and  soothing  remedy  for  painful  swelling  and  hardness  of  the 
breasts,  a  remedy  far  more  efficacious  than  the  evaporating  lotions  often 
recommended.  The  operation  described  above  was  suggested  by  Caval- 
lini,  by  Michaelis,  and  by  Blundell,  and  actually  performed  by  Storer  of 
Boston  in  1869  to  stop  a  serious  haemorrhage  during  the  performance  of 
Csesarean  section. 

MuUer  suggested  a  modification  which  may  be  advantageous  when 
the  operator  has  no  reliable  assistant  to  grasp  the  uterus.  He  makes  a 
long  incision,  turns  the  uterus  out  entire,  and  surrounds  its  base  with  an 
elastic  ligature  which  is  tightened  before  the  uterus  is  opened.  This 
procedure  and  the  opening  into  the  uterus  must  be  very  rapidly  done, 
however,  if  the  child  is  to  be  rescued  from  asphyxia.  The  method  is 
specially  recommended  in  order  to  avoid  fouling  of  the  peritoneum,  but 
this  accident  can  be  easily  avoided  with  proper  sponge  packing. 

Combined  Ccesarean  Section  and  Complete  Hysterectomy.  —  In  certain 
cases  it  may  be  thought  advisable  to  complete  a  Csesarean  section  by  the 
complete  extirpation  of  the  uterus  and  its  appendages  ;  it  is  not  neces- 
sary to  give  any  special  description  of  this  procedure,  as  the  first  part 
is  merely  Caesarean  section  up  to  the  extraction  of  the  child,  and  the 
second  part  is  complete  abdominal  extirpation  (hysterectomy)  already 
fully  described. 

It  only  remains  for  me  to  describe  the  after  treatment  of  a  patient  who 
has  been  subjected  to  any  form  of  hysterectomy,  and  to  give  a  list  of  the 
instruments  and  dressings  which  should  be  provided  for  the  operation. 

After  Treatment.  — The  after  treatment  is  the  same  after  all  forms  of 
hysterectomy,  for  whatever  disease  performed ;  and  after  removal  of  the 
appendages.  The  patient  is  kept  on  her  back  with  the  knees  over  a 
good  firm  pillow,  and  the  head  and  shoulders  well  supported  by  an 
inclined  plane  of  pillows.  I  never  let  the  patient  move  from  this  position 
till  the  end  of  a  fortnight,  when  she  is  in  many  cases  ready  to  get  up ; 
though  the  separation  of  the  stump  in  an  extraperitoneal  hysterectomy 
may  keep  a  patient  on  her  back  for  a  much  longer  time.  jSTothing  but 
an  occasional  sip  of  warm  Avater  (ice  dries  the  tongue  and  creates  more 
thirst)  is  given  by  the  mouth  until  all  sickness,  if  any  there  be,  is  over ; 
and,  more  important  still,  till  the  flatus  passes  down  by  the  anus  :  then  a 
little  weak  tea  with  plenty  of  milk,  equal  parts  of  milk  and  hot  water, 
milk  and  soda  water,  some  of  the  meat  essences,  pure  clear  beef  tea,  or 
mutton  or  chicken  broth,  may  be  taken ;  about  the  third  or  fourth  day  a 
little  boiled  fish,  or  sweetbread,  is  ordered,  and  so  gradually  an  ordinary 
diet  is  reached. 

Rectal  Feeding.  —  All  my  patients  are  fed  by  the  rectum,  every  three 
hours,  from  the  time  they  are  conscious  after  the  operation,  till  they  are 
taking  sufficient  nourishment  by  the  mouth;  and  clear  jelly  beef  tea 
made  as  strong  as  it  can  be  made  Avithout  salt,  is  the  only  thing  used  for 
these  injections. 


640  SyST£J/   OF  GYNECOLOGY 

Opium.  — In  this  injection  twenty  drops  of  laudanum  are  given  every 
six  hours,  unless  I  see  some  reason  to  omit  them;  for  I  am  still  convinced 
that  the  majority  of  cases  do  better,  and  are  more  comfortable  during 
the  first  fcAV  days,  with  laudanum  than  without  it.  I  rarely  continue 
its  use  beyond  the  third  or  fourth  day.  Any  medicine,  that  it  may  be 
necessary  to  give,  is  administered  also  in  the  injections.  If  the  injections 
are  not  well  absorbed  and  the  refuse  is  offensive,  the  rectum  is  washed 
out  with  half  a  pint  of  warm  water  and  rested  for  half  an  hour.  Two 
to  five  grains  of  quinine  mixed  with  a  tablespoonf  ul  of  port  wine  are  then 
added  to  each  injection;  this  destroys  septic  elements,  and  the  rectum 
will  soon  absorb  well  again.  I  have  seen  a  patient  at  death's  door  from 
septicaemia,  brought  on  by  injudicious  rectal  feeding,  and  allowing  a  lot 
of  decomposing  stuff  to  remain  in  the  rectum.  The  vaginal  pipe  of  a 
Higginson's  syringe  should  always  be  passed  into  the  rectum  ten  minutes 
before  an  injection  is  given,  to  allow  the  wind  to  pass,  and  to  let  any 
fluid  escape,  a  little  soap  dish  or  a  towel  being  placed  under  its  open 
end  to  absorb  the  latter.  If  the  rectum  be  irritable  it  is  a  good  plan  to 
wash  it  out  with  half  a  pint  of  warm  water,  or  with  the  same  quantity  of 
a  solution  of  borax,  or  boracic  acid,  to  allow  it  to  rest  for  half  an  hour, 
and  then  begin  the  injection  again.  Sickness  or  retching  I  treat  by 
large  doses  of  hot  water ;  sometimes  a  teaspoonf ul  of  sal  volatile  in  a 
tumbler  of  hot  water  acts  as  an  excellent  quick  emetic,  and  is  also  a 
little  stimulating.  Chloroform  sickness  is  allayed  by  15-grain  doses  of 
oxalate  of  cerium  in  mucilage  repeated  every  three  hours.  Sometimes 
when  the  flatus  does  not  pass,  and  green  sickness  is  troublesome,  a  dose 
or  two  of  white  mixture,  not  repeated  often  enough  or  given  in  large 
enough  dose  to  act  as  an  aperient,  acts  like  a  charm.  I  give  for  a  dose 
a  drachm  of  sulphate  of  magnesia,  with  a  scruple  of  the  carbonate,  and 
a  little  spirit  of  chloroform  in  an  ounce  of  peppermint  water. 

Drainage. — If  a  drainage  tube  be  used  the  wound  is  dressed  night 
and  morning,  the  sponges  in  the  india-rubber  sheet  washed  and  re- 
carbolised,  and  the  fluid  in  the  glass  tube  carefully  sucked  out  with  an 
india-rubber  tube  attached  to  the  nozzle  of  a  glass  syringe ;  the  rubber 
tube  should  have  a  round  hole  cut  in  its  side,  near  the  end  which  goes  to 
the  bottom  of  the  glass  tube,  or  it  will  suck  against  the  pelvic  peritoneum 
and  not  act  properly.  It  is  well  also  at  each  dressing  to  lift  the  glass 
tube  a  little,  and  to  turn  it  round  in  the  wound ;  as  little  bits  of  fat,  or 
omentum,  or  even  the  wall  of  the  gut,  may  be  drawn  into  its  side  holes 
and  get  strangulated  there,  causing  great  difficulty  in  its  subsequent 
extraction.  When  there  is  no  longer  anything  in  the  sponges,  and  only 
a  little  clear  serum  in  the  tube,  it  is  removed.  If  there  be  any  doubt  as 
to  the  exact  time  when  it  is  a(lvisal)lo  to  remove  it,  a  rubber  tube  may 
be  slipped  through  it,  long  enough  f(jr  the  glass  tube  to  be  witlidrawn 
over  it,  and  the  rubber  one  h^ft  in  for  another  twelve  or  twenty-four 
hours ;  so  that  if  fluid  still  gathers  it  may  escape  into  the  dressing.  The 
glass  tube  does  in  some  cases  irritate  the  peritoneum,  causing  a  flow  of 
serum,  and  also  some  trouble  with  flatulence;  and  it  may  be  difficult  to 


HYSTERECTOMY  641 


decide  whether  an  increased  flow  of  serum  be  due  to  this  cause  or  to 
septicity. 

Removal  of  Sutures.  —  In  an  ordinary  case,  where  the  wound  is  entirely 
closed,  I  rarely  dress  till  the  fifth  or  sixth  day ;  I  then  remove  half  the 
sutures;  on  dressing  again  in  three  or  four  days  I  remove  the  rest, 
strapping  up  carefully  after  each  dressing  with  strong  broad  straps  of 
adhesive  plaster,  which  is  much  better  than  any  soft  form  of  roller 
bandage,  as  the  firm  support  of  the  plaster  does  not  allow  the  intestines 
to  become  distended  with  gas.  In  extraperitoneal  hysterectomy  cases,  I 
am  guided  as  to  the  time  for  change  of  dressing  by  the  presence  or 
absence  of  any  staining  of  the  plaster,  or  by  the  necessity  for  tightening 
the  screw ;  this  I  often  do,  however,  through  a  little  window  without 
disturbing  the  rest  of  the  dressing.  Usually  the  hysterectomy  cases  are 
dressed  about  the  fourth  or  fifth  day,  and  then  every  third  day  till  the 
stump  begins  to  separate ;  then  I  dress  every  day  or  every  other  day, 
thoroughly  dusting  everything,  as  I  raise  the  old  dressings,  with  a  little 
pepper  dredger  full  of  finely  powdered  boracic  acid.  If  this  be  done  the 
stump  will  separate  without  smell,  which  is  a  great  comfort  to  the  patient, 
if  it  be  not  also  a  safeguard.  I  generally  leave  in  the  sutures,  or  some  of 
them  at  any  rate,  longer  in  these  cases,  as  the  wounds  are  very  liable  to 
reopen  if  the  sutures  are  taken  out  too  soon.  Whether  this  tendency  be 
due  to  the  nearness  of  septic  material  in  the  stump,  or  to  the  mechanical 
wedge-like  action  of  the  latter,  I  cannot  say  :  I  think  both  agencies  play 
their  part.  It  is  worthy  of  note  that  patients  operated  upon  during 
pregnancy  are  specially  liable  to  this  accident.  Careful  strapping  of  the 
wound  for  a  considerable  time  after  extraperitoneal  hysterectomy  is  ad- 
visable, to  try  to  prevent  the  occurrence  of  hernia  at  the  point  where 
the  stump  is  fixed ;  this  accident  is  of  such  common  occurrence  that,  to 
my  mind,  it  is  the  greatest  objection  to  this  method  of  operating.  These 
patients  should  be  specially  cautioned  not  to  expose  themselves  to  any 
risk  of  stretching  the  scar,  until  the  changes  from  soft  elastic  new  tissue 
to  firm,  fibrous,  old  scar  tissue  have  had  time  to  occur.  I  always  order 
all  my  patients  to  wear  a  good  supporting  abdominal  belt ;  and  I  do  not 
let  them  leave  it  off  till  I  have  examined  the  scar,  and  seen  that  it  is  firm 
and  linear.  I  do  not  in  the  least  believe  in  the  allegation  that  support 
weakens  the  muscles  and  tends  to  produce  hernia.  A  little  practical 
observation  in  a  matter  of  this  kind  is  worth  bushels  of  opinions,  and  I 
notice  that  patients  who  leave  off  their  belts  too  soon  are  very  liable  to 
hernia. 

Instruments  and  Dressings.  — The  following  are  the  instruments  and 
dressings  which  I  provide  for  an  operation,  whether  it  be  a  simple  re- 
moval of  the  appendages,  or  a  difficult  hysterectomy  :  — 

About  twenty-five  Turkey  cup  sponges  of  varying  size,  and  one  large 
flat  ditto.  I  vary  the  number  from  time  to  time,  so  that  the  nurses 
should  really  have  to  count,  and  not  get  careless  in  this  most  important 
detail.  They  are  well  cleaned  in  washing  soda  and  water,  and  after 
repeated  rinsing  to  get  rid  of  the  soda,  are  placed  in  1-20  carbolic  lotion, 

2t 


642  SYSTEM  OF  GYNAECOLOGY 

w'hifcii,  just  before  the  operation  commences,  is  turned  into  1-40  lotion 
by  the  addition  of  an  equal  measured  quantity  of  hot  water.  If  the 
sponges  are  thoroughly  damp  and  clean,  I  believe  a  very  few  minutes' 
soaking  in  1-20  is  quite  sufficient  to  render  them  safe,  and  surgically  pure. 

A  thin  mackintosh  sheet,  large  enough  to  cover  the  chest  and  abdo- 
men, and  to  hang  well  over  the  sides  of  the  table,  with  an  oval  hole  cut 
in  it  from  4  to  8  inches  long,  and  3  inches  broad ;  the  edges  of  the  hole 
being  surrounded  with  an  inch  broad  layer  of  carbolised  adhesive  plaster. 

A  yard  of  strong  adhesive  plaster,  cut  into  strips  of  varying  width 
and  length,  suitable  to  the  particular  case. 

A  binder  made  of  fine  flannel,  lined  with  old  calico  turned  well  over 
the  edges  of  the  flannel,  so  that  when  the  binder  is  applied  the  flannel 
does  not  anywhere  touch  the  skin. 

Some  good  strong  safety  pins  of  the  old-fashioned  kind,  without  any 
cap  or  contrivance  for  harbouring  dirt. 

A  couple  of  packets  of  carbolised  gauze. 

One  lb.  of  carbolic  acid  or  absolute  phenol,  made  into  twenty  pints  of 
lotion  just  before  the  operation,  so  that  it  is  hot  and  ready  for  use.  An 
excellent  vessel  in  which  to  make  this  lotion  is  an  earthenware  or  china 
slop  jar,  obtainable  now  in  most  houses  ;  they  just  hold  twenty  pints  of 
fluid.  The  lotion  should  be  made  by  dissolving  the  acid  in  really  boiling 
water,  and  then  making  up  the  quantity  with  ordinary  hot  water. 

A  small  bottle  of  laudanum  for  the  nurse's  use  after  the  operation. 

A  bottle  of  glycerine  to  take  the  carbolic  acid  out  of  my  own  hands 
after  the  operation. 

A  small  bottle  of  tincture  of  iodine. 

A  wide-mouthed  bottle  of  solid  perchloride  of  iron. 

A  box  of  bistouries ;  a  Key's  director ;  a  long  straight  needle  with  a 
large  eye ;  an  Adam's  eye  hook  for  picking  up  the  peritoneum  ;  a  pair  of 
catch  forceps  for  pulling  out  the  tongue ;  two  dozen  straight  needles 
about  2\  inches  long,  threaded  in  pairs  with  No.  2  carbolised  Chinese 
twist,  and  arranged  in  a  piece  of  gauze. 

For  a  hysterectomy,  two  pairs  should  be  threaded  with  No.  3  silk  for 
use  above  and  below  the  pedicle. 

Two  or  three  curved,  long-handled,  perineum  needles,  armed  with  a 
long  thread  of  silk  —  No.  3  for  final  tying,  and  No.  4  for  temporary  use. 

Three  or  four  skeins  of  carbolised  Chinese  twist  wound  on  glass 
reels,  Nos.  1,  2,  3,  and  4. 

At  least  two  dozen  pairs  of  Wells'  pressure  forceps,  some  curved,  some 
straight ;  in  a  big  enucleation  hysterectomy  more  will  often  be  required. 
A  few  pairs  of  my  own  square-ended  forceps.  From  four  to  six  of  Wells' 
long  and  strong  j)ressure  forceps,  some  straight,  some  curved.  A  couple 
of  long,  narrow-bladcd,  temporary  clamps.  A  pair  of  scissors  curved  on 
the  flat.     A  scissors  handled  needle  holder. 

Two  or  three  of  Koeberle's  serre-naiids,  and  a  good  supply  of  soft 
iron  wires  of  various  lengths  and  thicknesses,  with  one  end  looped  ready 
for  use.     The  soft  iron  wire  is  much  to  bo  preferred  to  the  new  amalgam, 


MALIGNANT  DISEASES   OF   THE    UTERUS  643 

which  is  very  liable  to  yield,  and  allow  subsequent  oozing.  A  pair  of 
pliers  for  tightening  the  wire  and  cutting  it.  A  strong,  flatheaded  cork- 
screw with  loop  handle.  Some  of  my  pedicle  pins  with  screw  cap.  A 
pair  of  oval-ended,  long-handled  polypus  forceps,  with  catch  on  handles,  to 
be  used  for  introducing  the  sponges  into  the  pelvis.  A  fine  long  trocar 
and  caniila  suitable  for  exploratory  puncture.  An  assorted  series  of 
Keith's  ^lass  drainage  tubes,  a  rubber  sheet  for  use  with  tube,  a  glass 
syringe  armed  with  a  fine  piece  of  red  rubber  tube  for  sucking  out  con- 
tents of  glass  tube.  Some  rubber  tubing  of  various  sizes  suitable  for 
drainage,  or  to  use  as  a  temporary  elastic  ligature.  Uterine  and  bladder 
sounds. 

J.  Knowsley  Thorxtox. 


MALIGNANT  DISEASES   OE  THE   UTERUS 

Introductory. —  The  task  of  setting  forth  the  present  state  of  our 
theoretical  knowledge  and  of  our  practical  methods  of  dealing  with 
malignant  disease  of  the  uterus  does  not  include  the  consideration  of  the 
pathology  of  cancer  in  general.  We  have,  however,  sufficient  material 
for  a  more  definite  and  partial  treatment  of  the  subject. 

Malignant  disease,  as  met  with  in  the  female  sexual  organs,  presents 
certain  anatomical  naked-eye  changes  of  tissue  and  a  conformation  of 
neoplasms  which  is  peculiar  to  these  parts,  bat,  whatever  their  clinical 
importance,  they  are  of  comparatively  little  pathological  significance. 
But  there  are  other  considerations  —  such  as  frequency  of  occurrence, 
causation,  and  surgical  and  medical  methods  of  treatment — which  are 
highly  important,  and  which  require  special  exposition  on  account  of 
the  anatomical  structure  of  the  parts,  the  relations  of  the  affected  organ 
to  pelvic  and  other  viscera,  and  its  peculiar  physiological  functions. 

The  pathology  is  also  to  a  large  extent  special  on  account  of  the  minute 
anatomy  of  the  parts  affected,  the  relations  of  their  constituent  elements 
to  the  origin  of  the  malignant  process,  the  methods  of  invasion,  and  the 
extent  of  the  changes  produced  by  the  growth  of  the  neoplasm.  For  an 
exposition  of  the  present  state  of  the  science  of  bacteriology  in  relation 
to  malignant  disease  the  reader  is  referred  to  System  of  Medicine,  vol.  i. 
We  have  to  consider  the  practice  of  medicine  as  well  as  pathology ; 
and  the  two  subjects  are  not  always  so  mutually  helpful  and  comple- 
mentary as  might  have  been  expected.  Some  of  the  pathologists  who 
have  given  special  attention  to  this  subject  may  be.  perhaps,  too  prone  to 
attach  imdue  importance  to  their  methods  of  investigation,  to  multiply 
non-essential  details,  and  to  magnif}'"  unimportant  differences,  which  ob- 
scure the  view  in  the  direction  of  general  conclusions.  They  naturally 
become  absorbed  in  the  contemplation  of  the  specimens  which  are  to 


644  SYSTEM  OF  GYNECOLOGY 

them  the  subject  material  for  observation  and  reflection ;  they  are  not 
concerned  with  the  aspects  of  disease  and  its  human  interest.  The 
clinician,  on  the  other  hand,  has  ever  with  him  the  human  interest  of 
the  disease,  and  he  looks  sometimes  impatiently  toAvards  the  pathologist 
for  practical  guidance  in  dealing  with  the  individual  case.  It  is  to  him 
of  small  interest  Avhat  name  the  nomenclature  of  the  decade  assigns  to 
a  certain  conformation  of  epithelial  or  connective  tissue  elements.  He 
wishes  to  know  whether  the  disease  in  question  is  malignant  or  benign ; 
and  he  may  occasionally  be  harsh  and  unjust  in  his  judgments  of  scien- 
tific pathology  when  the  answers  are  not  so  prompt  and  lucid  as  he 
may  have  expected. 

In  the  exposition  of  malignant  disease  of  the  uterus  within  reason- 
able limits,  considering  the  inherent  difficulties  and  the  present  state  of 
our  definitely  acquired  knowledge,  I  can  only,  to  the  best  of  my  judg- 
ment, assign  the  space  which  I  think  suitable  to  each  part  of  the  subject; 
hoping  for  the  early  advent  of  the  time  Avhen  pathology  and  practical 
gynsecology  will  be  more  helpful  to  each  other  than  they  are  now,  and 
the  material  for  their  exposition  may  be  more  complete  and  homogeneous. 
If  I  err  on  one  side  the  pathologist  may  think  my  work  incomplete  and 
unsatisfactory,  perhaps  puerile  and  shallow;  if  I  err  on  the  other  side, 
the  gynaecologist  may  consider  the  result  tedious  and  unintelligible, 
perhaps  pretentious,  certainly  unpractical. 

Cancer  of  the  uterus,  as  popularly  understood,  implies  the  existence 
of  a  growth  or  tumour  whose  most  striking  characteristics  are  —  the  ten- 
dency to  spread  by  sending  out  roots  in  all  directions  from  the  point  of 
origin,  so  as  gradually  to  destroy  the  womb  itself ;  and  in  the  process  to 
produce  such  symptoms  as  intense  pain  and  foul  discharges,  distressing 
to  the  patient  and  those  about  her,  and  finally  to  cause  a  lingering 
and  miserable  death.  The  popular  notion  of  j^ain  as  an  essential 
symptom  in  such  a  terrible  malady  interposes  one  of  the  principal  diffi- 
culties in  the  way  of  seeing  the  cases  in  the  earlier  stages  of  the  disease, 
and  of  applying  the  most  efficient  treatment. 

Another  jjopular  notion,  which  I  fear  is  also  held  in  some  vague  and 
uncertain  way  by  many  members  of  the  medical  profession,  is  that  the 
menojjause  is  associated  with  irregular  and  profuse  haemorrhage  from 
the  uterus,  and  even  with  other  discharges  from  the  uterus  or  pudenda. 
This  widely-accepted  theory  of  a  final  *'  cleansing,"  as  a  disagreeable 
episode  necessitating  patient  waiting  for  its  terndnation,  is  one  of  the 
principal  reasons  why  long  delay  so  often  occurs  before  women  affected 
with  cancer  of  the  uterus  seek  professional  advice ;  and  it  is  to  be  feared 
that  it  sometimes  accounts  for  the  fact  that  the  advice  obtained  is  not 
always  based  on  jtrecise  diagnosis,  followed  by  prompt  and  effective 
treatment. 

Jn  order  to  formulate  our  knowledge,  to  facilitate  the  description  of 
symptoms,  and  to  indicate  the  sequence  and  relations  of  processes  and 
phenomena,  it  is  necessary  for  us  to  classify  the  most  striking  forms 
which  malignant  diseases  of  the  uterus  assume.     We  must  constantly 


MALIGNANT  DISEASES   OF  THE    UTERUS  645 

keep  in  mind,  however,  that  these  classifications  apply  with  any  preci- 
sion only  to  the  comparatively  early  stages  of  the  disease;  and  we  must 
also  remember  that  the  terms  which  we  employ  only  indicate  the  pres- 
ence of  pathological  tendencies  producing  certain  tissue  changes.  The 
ultimate  facts  determining  their  origin  and  their  relationships  are  still 
unknown  to  us.  The  malignant  diseases  that  Ave  call  epithelioma,  car- 
cinoma, and  sarcojua,  may  all  be  present  in  the  same  individual.  This 
co-existence  of  disease  in  the  various  forms  implies,  so  far  as  we  know, 
no  more  than  a  greater  measure  of  some  condition  of  the  general  health 
determining  degenerations  of  which  our  exact  knowledge  is  so  limited 
that  controversy  can  hardly  be  said  to  have  begun ;  but  it  -would  seem 
to  suggest  that  the  various  tumour  forms  assumed  by  tissues  under  the 
malignant  process  do  not  differ  so  essentially  as  we  are  apt  to  believe 
Avhen  we  look  at  them  too  narrowly  on  the  histological  side. 

With  regard  to  the  most  common  early  forms  of  malignant  disease, 
epithelioma  and  carcinoma,  much  has  been  written  in  recent  years; 
but  there  is  little  that  can  be  called  new  in  the  recent  literature  of  the 
pathology,  whereas  enormous  advances  have  been  made  during  the 
same  time  in  the  therapeutics,  especially  surgical,  of  malignant  dis- 
eases of  the  uterus.  Perhaps,  from  the  pathological  point  of  view,  the 
most  important  question  at  the  present  time  is  the  position  of  adenoma. 
Within  the  last  few  years  much  has  been  added  to  the  literature  of  this 
subject,  and  although  there  is  considerable  difference  of  opinion,  the 
tendency  at  the  present  time  appears  to  be  to  recognise  its  compara- 
tively frequent  occurrence  in  a  malignant  form,  and  to  place  it  in  a 
separate  category  from  carcinoma. 

The  most  recent  of  all  questions  with  regard  to  the  malignant  diseases 
of  the  uterus  is  the  character  and  seat  of  origin  of  "deciduoma  malignum."' 
The  subject  is  comparatively  of  little  importance  from  the  practical  stand- 
point, because  of  the  rare  occurrence  of  cases  ;  but  from  the  point  of  view 
of  the  pathologist  few  subjects  coidd  be  more  interesting.  There  can  be 
little  doubt  that  the  extraordinary  amount  of  attention  which  this  subject 
has  received,  is  bound  to  bring  about  not  only  a  considerable  increase  in 
our  knowledge  of  the  changes,  both  normal  and  pathological,  Avhich  occur 
in  the  postpartum  uterus,  but  also  to  add  to  our  knowledge  of  the  devel- 
opment, the  normal  physiology,  and  the  pathology  of  the  placenta. 

In  the  following  pages  the  names  epithelioma,  carcinoma,  and  sar- 
coma are  used  in  the  ordinarily  accepted  sense — the  two  former  indi- 
cating a  malignant  new  growth  of  epithelial  origin,  the  last  imi^lying  a 
malignant  neoplasm  of  connective  tissue  origin.  Other  names,  such  as 
"adenoma  malignum"  and  "deciduoma  malignum,"  may  be  accepted 
provisionally  as  implying  certain  characteristics  to  be  discussed  in  deal- 
ing Avith  them  in  their  proper  place.  Whether  they  should  be  retained 
in  our  nomenclature  is  a  question  Avhich  can  be  settled  only  when  dis- 
cussion and  observation  have  produced  something  like  unanimity  of 
opinion  concerning  the  origin  and  structure  of  the  tumours,  and  the 
course  and  symptoms  of  the  ailments  resulting  from  their  growth. 


646  SYSTEM  OF  GYX.-ECOLOGY 

The  classification  of  the  malignant  diseases  of  the  uterus  which  Avill 
be  adopted  here  as  most  suitable  to  the  present  state  of  our  knowledge, 
and  as  most  convenient  for  exposition,  is  the  following :  —  I.  Epithe- 
lioma et  carcinoma  portionis  vaginalis  uteri ;  II.  Carcinoma  cervicis 
uteri ;  III.  Carcinoma  corporis  uteri ;  IV.  Sarcoma  corporis  et  cervicis 
uteri ;  Y.  Adenoma  malignum  (corporis  et  cervicis  uteri) ;  VI.  Decidu- 
oma  malignum.  The  varieties  or  subdivisions  of  each  form  will  be 
described  and  discussed  in  their  proper  places. 

I.  Cancer  of  the  Vaginal  Portion  of  the  Uterus.  —  Pathologiccd 
Anatomy.  —  The  pathological  anatomy  of  cancer  of  the  vaginal  por- 
tion and  cervix  forms  a  very  difficult  and  extensive  chapter  in  any 
exposition  of  malignant  disease  of  the  uterus.  The  mass  of  pub- 
lished observations,  both  clinical  and  histological,  is  so  enormous,  and 
the  views  of  pathologists  who  have  devoted  much  attention  to  the 
subject  are  so  diverse  and  even  contradictory,  that  at  first  sight  it  is 
diffictdt  to  detect  any  sort  of  order  in  the  chaos.  When  we  remember, 
too,  the  great  amount  of  controversy  which  has  taken  place  on  almost 
every  detail  of  published  observation,  and  the  impossibility  for  each 
author  or  expositor,  for  the  time  being,  absolutely  to  divest  himself 
of  some  preconceived  opinion  or  bias,  we  may  readily  conclude  that  the 
easiest,  and  perhaps  the  best  course  is  to  rest  satisfied  with  endeavour- 
ing to  record  concisely  the  state  of  knowledge  and  opinion  at  the  time 
of  writing. 

The  vast  mass  of  observation  and  opinion  previously  on  record  has 
been  greatly  increased  within  recent  years,  when  the  bulk  of  the  pro- 
fession in  Europe  and  America  has  declared  so  steadily  in  favour  of 
extirpation  in  the  treatment  of  malignant  disease  of  the  uterus.  Not  only 
has  exact  clinical  and  macroscopic  observation  become  more  confident, 
exact,  and  practically  useful,  but  the  material  obtained  for  the  histologist 
and  pathologist  in  comparatively  early  stages  of  the  disease  by  operation 
and  post-mortem  examination,  has  become  vastly  more  various  and 
interesting,  as  well  as  incomparably  greater  in  amount.  To  the  same 
cause  also  we  owe  the  fact,  all  important  for  the  practical  application 
of  the  pathological  knowledge  acquired,  that  clinical  observation  and 
histological  investigation  have  become  more  closely  associated.  As  an 
illustration  of  the  industry  with  which  observations  are  made  and 
published,  it  may  be  mentioned  that  the  last  three  volumes  of  the 
Jahresbericht  iiber  die  Fortschritte  auf  clem  Oehiete  der  OehurtHliulfe  und 
GyndJcolor/ie,  ending  with  1894,  contains  references  to  528  contributions  on 
the  malignant  diseases  of  the  female  sexual  organs  alone.  We  may  ask 
whether  progress  in  the  acquisition  of  exact  knowledge  of  the  pathology 
of  uterine  cancer  has  been  great  in  proportion  to  the  facility  of  obtaining 
material  and  associating  the  observations  with  the  history  of  individual 
cases ;  and  whether  the  progress  of  pathological  knowledge  has  corre- 
sponded with  greater  precision  of  diagnosis  and  treatment  by  the  prac- 
tical gynaecologist?     On  this  point,  it  must  be  confessed,  there  is  much 


MALIGNANT  DISEASES    OF   THE    UTERUS  647 

reason  to  answer  with  hesitation.  Even  the  most  recent  text-books  or 
manuals  of  gynsecology  show  strongly  the  influence  of  authority  in  their 
pathology,  for  their  authors,  after  critical  analysis  of  the  statements  and 
opinions  expressed  in  the  reports  of  the  earlier  observations,  implicitly 
admit  that  they  must  accept  them  as  final  and  complete.  And  yet 
there  is  a  good  deal  in  what  appears  as  description  of  personal  observa- 
tions which  must  have  contained  an  important  element  of  inference ;  and 
it  may  be  alleged  without  undue  rashness  that  some  conclusions  offered 
by  the  pathologists,  and  given  practical  effect  to  by  the  gynaecologists, 
have  not  been  justified  by  the  exact  clinical  observations  of  recent  years. 
We  may  safely  assert  that  the  expectations  founded  by  practical  men  upon 
the  earlier  investigations  into  the  origin  of  cancer  of  the  cervix  have 
been  doomed  to  disappointment;  that  no  light  has  been  thrown  by 
the  labours  of  the  pathologists  upon  the  etiology  of  cancer  of  the  cer- 
vix, and  that  little  guidance  has  been  obtained  in  the  treatment  of  the 
disease.  Still  we  have  hope  for  the  future,  and  all  careful  observations, 
however  remote  from  obvious  practical  ends,  must  be  Avelcomed  and 
studied.  Any  statement,  however  concise,  of  the  views  of  the  inquirers 
into  the  histology  of  early  cancer  which  may  be  assumed  to  be  necessary 
to  completeness  in  the  exposition  of  the  subject,  can  hardly  be  made  clear 
and  independently  readable  without  a  short  summary  of  the  normal 
minute  anatomy  of  the  parts. 

For  the  present  purpose  we  must  keep  in  mind  that  the  cervix  uteri 
consists  of  (i.)  a  vaginal  portion,  and  (ii.)  a  supravaginal  portion  extend- 
ing to  the  isthmus,  where  it  joins  the  corpus  uteri.  The  vaginal  portion 
projects  as  a  dome  or  truncated  cone  from  the  vaginal  vault,  and  is,  when 
normal,  firm  and  resistant  to  the  touch,  and  perfectly  smooth,  hence  the 
terms  os  tinccti  or  museau  de  tanche.  On  visual  inspection  the  nulliparous 
vaginal  portion  is  found  in  health  to  be  of  a  pale  pink  colour  ;  and  the 
appearance  of  its  surface  confirms  the  impression  of  smoothness  given  to 
the  sense  of  touch.  It  is  planted,  as  it  were,  in  the  centre  of  the  vagina, 
and  around  it  there  is  an  indefinite  boundary,  where  the  smooth  mucous 
covering  of  the  vaginal  portion  gives  way  to  the  rougher  and  harder 
vaginal  lining.  The  existence  of  this  boundary  is,  I  believe,  a  point  of 
some  interest  and  importance  in  the  spread  of  epithelioma  of  the  vaginal 
portion.  The  os  externum,  or  opening  of  the  cervical  canal,  is  the  most 
striking  feature  presented  by  the  vaginal  portion.  In  the  j^erfectly 
normal  nulliparous  uterus  it  may  be  oval  or  round ;  its  edges  are  indicated 
by  the  deeper  colour  of  the  margin  of  the  cervical  mucous  lining,  which 
generally  can  be  more  or  less  distinctly  seen ;  and  it  is  situated  rather 
behind  than  at  the  centre  of  the  most  prominent  spot,  because  of  the 
slightly  greater  bulk  of  the  anterior  lip.  The  parous  or  multiparous  os 
externum,  when  the  uterus  is  in  a  state  of  complete  involution,  may  var}' 
considerably  Avithin  the  limits  of  health.  It  is  seldom  free  from  marks 
of  injury:  there  are  fissures,  more  or  less  deep;  retention  cysts,  some 
of  which  may  have  ruptured,  give  rise  to  the  appearance  of  small 
ulcerations ;  others  may  have  dried  or  shrivelled  up,  producing  minute 


64S  SyST£J/  OF  GYNECOLOGY 

T\'hite  specks  on  or  just  within  the  apparent  margin  of  the  cervical  canal. 
The  area  of  exposure  of  the  red  cervical  lining  is  invariably  larger  in 
appearance  than  in  the  nullipara,  chiefly  because  the  os  is  more  open. 
Deeper  fissures  or  lacerations  producing  lobulation  of  the  vaginal  portion 
with  ectropium,  hypersecretion,  induration  with  prominent  retention 
cysts,  increase  in  volume,  and  other  related  changes,  should  be  looked 
upon  as  pathological  conditions.  Between  this  higher  limit  of  deeper 
coloured  lining  about  the  os,  and  that  lower  limit  where  the  smooth  and 
soft  mucosa  shades  off  into  the  comparatively  hard  and  rugated  vagina, 
the  portio  vaginalis  has  been  aptly  described  by  Sir  John  Williams  "  as  a 
cup  of  stratified  epithelium,  resembling  a  tailor's  thimble,  which  fits  on 
the  lower  end  of  the  cervix  proper."  The  layers  of  epidermis  in  health 
conceal  the  vascular  papillae;  but  the  presence  of  these  is  obvious  to 
the  naked  eye  in  the  early  stage  of  catarrh  of  the  portio,  by  the 
scarlatinal  appearance  of  the  reddened  mucosa  from  which  the  epider- 
mis has  been  partially  shed.  In  health  this  mucous  covering  can  be 
felt  to  glide  over  the  firm  muscular  mass  of  the  cervix  u.nderlying  it; 
and  in  some  diseased  conditions  it  can  be  readily  peeled  off,  like  wet 
paper,  so  as  to  expose  the  chorion  with  its  torn  and  bleeding  papillary 
vessels  underneath. 

Between  the  vaginal  portion  with  its  squamous  epithelium,  and  the 
true  cervical  mucous  membrane  with  its  cylindrical  epithelium  and  in- 
numerable gland  structures,  there  is  a  narrow  band  where  the  epithelium 
is  transitional,  chiefly  of  a  cubical  form,  and  the  glands  fewer  but  still 
numerous.  The  existence  of  a  debatable  border  or  belt,  which  may  in 
diseased  conditions  be  invaded  from  above  by  glandular  or  papillary 
structures  resembling  carcinoma,  or  from  below  by  the  squamous  epithe- 
lium of  the  portio,  has  been  too  readily  accepted  by  the  gynaecologists 
from  the  pathologists.  In  support  of  the  existence  of  this  variable  belt 
it  is  said  that  there  is  occasionally  great  difficulty  in  making  out  the  line 
of  demarcation  between  the  portio  vaginalis  and  cervix.  This  line  is, 
however,  almost  certainly  much  more  constant  than  is  so  often  stated, 
even  when  on  simple  inspection  it  seems  most  obscured  by  the  effects  of 
exposure,  of  injuries,  or  of  a  catarrhal  process.  The  cervical  portion 
secretes  an  alkaline  fluid,  and  the  surface  of  the  portio  vaginalis  is  always 
moist  with  an  acid  exudation  or  secretion.  If  a  piece  of  litmus  paper  be 
laid  across  the  doubtful  margin,  which  has  been  gently  wiped  with  dry 
cotton  wool,  the  dividing  line  will  be  always  found  exact  and  definite; 
the  moisture  on  the  reddened  surface  of  the  apparent  portio  is  always 
acid,  that  of  the  area  of  cervical  lining,  even  when  obscured  by  ulcerat- 
ing retention  cysts  or  ectropium,  is  always  alkaline.  This  test  may 
be  applied  with  advantage  in  an  old  laceration  of  the  cervix  with  hyper- 
trophy and  flattening  out  and  erosion  by  contact  with  the  vaginal  wall. 
It  is  a  guide  to  boundaries,  and  ma}^  show  how  much  has  to  be  done 
to  restore  the  vaginal  portion  by  operation.  With  regard  to  the 
mucous  membrane  of  the  cervix  it  may  be  best  to  quote  the  following 
description:  it  "is  much  firmer  and  more  fibrous  than  that  of  the  body. 


MALIGNANT  DISEASES   OF  THE    UTERUS  649 

Between  the  rugae  of  the  arhor  vitce  there  are  numerous  saccular  and 
tubular  glands.  In  the  lower  part  of  the  cervix  the  mucous  membrane 
is  beset  with  vascular  papillae,  and  the  epithelium  is  stratified,  but  in 
the  upper  half  or  more  the  epithelium  is  columnar  and  ciliated  like  that 
of  the  body.  The  glands,  which  are  short,  with  large  lumen,  are  every- 
where lined  with  columnar  ciliated  epithelium,  even  Avhere  the  epitheliiim 
of  the  surface  is  stratified.  Besides  the  follicular  glands  there  are  almost 
constantly  to  be  seen  the  so-called  ovula  Nabothi,  clear  yellowish  vesicles 
of  variable  size,  but  visible  to  the  naked  eye,  embedded  in  the  mem- 
brane "  (37). 

In  describing  the  relevant  points  in  the  structure  of  the  parts  under 
consideration,  there  is  one  more  margin  or  boundary  which  should  be 
mentioned  as  of  interest  in  relation  to  cancer  of  the  cervix.  This  is  the 
upper  termination  of  the  cervical  canal  where  it  is  marked  off  by  a  con- 
striction, the  OS  internum,  beyond  which  the  cavity  of  the  body  begins. 
Just  below  the  narrowest  point  at  the  junction  of  the  canal  of  the  cervix 
and  of  the  body  there  is  a  narrow  band  of  mucous  membrane,  which 
in  structure  more  nearly  resembles  the  mucosa  of  the  body  than  that  of 
the  cervix.  Kilstner  says  of  this  border  line  that  microscopically  no 
difference  can  be  made  out  between  ^  cm.  of  the  cervical  mucous 
membrane  and  an  equal  measure  of  the  corporeal  lining  immediately 
adjoining,  either  as  regards  the  form  and  arrangement  of  glands  or  the 
form  of  the  cells.  Although  there  is  no  proof  that  this  portion  of  the 
canal  undergoes  the  changes  in  the  structure  of  the  corporeal  mucosa 
which  are  characteristic  of  menstruation,  its  participation  in  corporeal 
pathological  changes  which  do  not  extend  to  the  cervix  as  a  whole  is  such 
as  to  supply  important  diagnostic  features  ;  as,  for  example,  in  catarrh 
of  the  corporeal  endometrium,  which  produces  a  tender  spot  just  below  the 
OS  internum  while  the  rest  of  the  endometrium  of  the  cervix  is  com- 
paratively insensitive.  It  is  just  at  this  narrow  circle  of  tissues  in  the 
transition  stage  between  cervix  and  body  that  the  malignant  ulceration 
spreading  from  epithelioma  of  the  cervix  appears  to  be  arrested  to  a  very 
great  extent,  and  when  checked  to  extend  more  rapidly,  and  to  a  larger 
extent,  into  the  muscular  substance  and  the  parametrium. 

The  check  to  the  process  of  ulceration  at  this  spot,  and  the  irregular 
hypertrophy  from  cell  proliferation  which  takes  its  place,  are  probably 
the  immediate  causes  of  the  pyometra  which  is  so  frequently  met  with 
in  fairly  advanced  post-climacteric  cases ;  and  the  obstruction  produced 
by  hypertrophy  must  be  a  factor  in  the  production  of  pain  as  a  symptom 
of  advancing  cancer  of  the  cervix  in  younger  women. 

Elements  of  Orujhi  of  the  Disease. — The  discussion  of  the  ultimate 
facts  in  the  origin  of  malignant  disease  of  the  portio  vaginalis  and  cer- 
vix uteri  does  not  help  us  much  either  in  theory  or  practice.  The  differ- 
ences of  opinion  amongst  the  pathologists  are  too  marked  to  make  it 
possible  for  those  wlio  have  not  specially  worked  at  the  subject  to  form 
an  intelligent  judgment ;  and  in  practice,  while  there  is  room  for  fearing 
that  the  plausibility  ;tud  symmetry  of  some  theories  have  led  to  practical 


650  SYSTEM   OF  GYNAECOLOGY 

applications  uot  altogether  satisfactory,  the  vast  mass  of  detailed  descrip- 
tion, and  the  conclusions  drawn  from  microscopic  observations  by  pathol- 
ogists are  not  so  far  accepted  as  exact  and  well-established  as  to  warrant 
confident  practical  conclusions  on  the  part  of  the  gynsecologist.  Most  of 
the  theoretic  teaching,  moreover,  may  be  looked  ujDon  as  merely  the 
application  of  theories  of  cancer  in  general  to  the  uterus  in  particular;  it 
is  largely  doctrinaire  and  irrelevant  to  practical  gynaecology. 

Whether  the  ultimate  fact  be  some  change  occurring  in  connective- 
tissue  cells  alone  or  in  epithelial  cells  we  do  not  yet  know ;  the  decision 
may  have  far-reaching  consequences  in  our  methods  of  treatment,  but 
the  discussions  are  not  yet  drawing  to  an  end.  The  habit  of  patholo- 
gists in  drawing  upon  embryonic  tissue,  either  persistent  in  some  latent 
form,  or  reappearing  in  adult  organs,  in  forming  and  supporting  hypoth- 
eses, appears  to  the  practical  man  to  produce  ill-defined  shades  of 
opinion  not  conducive  to  clearness  of  comprehension  or  to  practical  ends. 
It  is  still  true,  as  stated  by  Gusserow  (14),  that  our  comprehension  of 
the  anatomy  of  malignant  tumours  has  been  greatly  obscured  by  the 
multiplicity  of  observations,  and  by  the  discussions  on  the  point  of  origin 
of  cancerous  tumours.  So  far  as  I  know,  Virchow  was  the  author  of 
the  theory  of  the  connective-tissue  origin  of  carcinoma  of  the  cervix,  and 
with  the  name  of  Waldeyer  we  associate  the  opposing  view  that  pre- 
viously existing  epithelium  is  the  starting-point.  Both  theories  recognise 
the  epithelial  character  of  cancerous  growths,  whether  we  call  them 
carcinoma  or  epithelioma.  Klebs  supports  the  theory  of  the  epithelial 
origin  of  malignant  disease  of  the  cervix.  The  transitional  or  cubical 
epithelium  just  within  the  os  externum  begins  to  proliferate,  penetrates 
into  the  stroma  of  the  mucous  membrane,  and  even  into  the  underlying 
muscular  tissue,  and  causes  occlusion  or  destruction  of  blood-vessels,  and 
consequent  necrosis  and  loss  of  substance  within  the  vaginal  portion  and 
cervix.  The  squamous  epithelium  of  the  portio  vaginalis,  especially  the 
cells  of  the  rete  Malpighii,  becomes  the  seat  of  papillary  hypertrophy  ; 
there  is  in  the  same  way  invasion  of  the  subjacent  structures,  and 
consequent  necrosis  and  breaking  down.  Thus  originate  the  cancer- 
ous ulcers  and  papillary  growths  of  the  vaginal  portion.  With  regard 
to  carcinoma  of  the  cervix,  Klebs  maintains  that  it  is  also  of  direct  epi- 
thelial, not  of  connective-tissue  origin,  as  was  formerly  believed.  The 
starting-point  is  in  the  epithelium  of  constricted  cervical  glands  ;  and  he 
assumes  a  tendency  of  the  ovula  Nahothi  in  the  vicinity  of  the  internal  os 
to  undergo  cancerous  changes. 

Ruge  and  Veit,  whose  work  has  received  so  much  attention,  main- 
tain that  the  pavement  epithelium  of  the  portio  is  never  the  point  of 
origin  of  epithelioma  or  cancer  of  the  vaginal  portion ;  not  even  of  the 
"  cauliflower  excres(!ence."  The  starting-point  is  either  in  the  deeper 
connective  tissue  or  in  the  newly  formed  glands  found  in  tlioir  follicular 
and  papillary  ''  erosions."  Hence  the  seat  of  origin  of  this  cancerous 
growth  is  outside  the  os  externum,  and  it  does  not  extend  towards  the 
cervix  ;  its  dovelopinent  is  towards  the  vagina  and  parametrium  —  aeon- 


MALIGNANT  DISEASES   OF  THE    UTERUS  651 

elusion  carrying  serious  praetieal  results.  The  connective  tissue  stroma 
becomes  vascularisecl  and  passes  into  the  embryonic  condition,  and  the  new 
cellules  assume  an  epithelioid  aspect.  Exceptionally,  these  authors  have 
seen  adenomatous  vegetations  of  glandular  epithelium  origin  give  rise  to 
carcinoma ;  but  they  never  saw  plugs  of  epithelium  extending  down  into 
the  connective  tissue.  So,  symmetrically  as  it  were,  it  is  the  connective 
tissue  of  the  walls  of  the  cervix,  or  of  the  glands  of  the  mucous  mem- 
brane, which  is  the  point  of  origin  of  carcinoma  of  the  cervix.  They 
assert  that  this  is  the  origin  of  a  form  of  malignant  disease  of  the  cervix 
which  does  not  extend  downwards  outside  the  os  externum,  but  spreads 
all  round,  destroying  the  cervical  tissues  and  extending  readily  upwards 
to  the  body  of  the  uterus. 

It  would  be  useless  to  multiply  opinions  on  this  subject.  There  is  a 
certain  element  of  controversy,  as  well  as  the  record  of  observations  in 
the  literature,  which  has  some  resemblance  to  the  discussion  at  present 
in  progress  concerning  the  point  of  origin  and  nature  of  "  Deciduoma 
malignum."  But  Rvige  and  Veit's  investigations  and  results  have  such  a 
captivating  conciseness  and  symmetry  about  them,  that  they  were  widely 
accepted,  and  have  almost  held  the  field  ever  since.  Their  influence  on 
gynaecology  was  perhaps  best  illustrated  by  the  work  of  Schroeder,  who 
might  almost  be  considered  their  exponent  in  practice  ;  and  his  influence 
is  still  seen  in  the  advocacy  of  certain  ineffective  methods  of  surgical 
treatment  of  cancer  of  the  vaginal  portion.  Connective-tissue  origin 
suggests  connective-tissue  relations,  hence  probably  the  theory  of  early 
invasion  of  the  parametrium  by  cancer  of  the  vaginal  portion,  and  con- 
sequent discouragement  of  the  radical  operations. 

Seat  of  Origin  of  Growth  in  its  earliest  Clinical  Aspect.  — From  the  in- 
vestigations and  h}' potheses  already  mentioned  it  would  be  easy  to  infer, 
in  anticipation  of  clinical  observation,  that  there  must  be  three  positions 
in  the  anatomical  sense  in  which  the  earliest  appearance  of  cancer  of 
the  portio  and  cervix  may  be  made  out :  (i.)  As  small  nodules  deep  in 
the  tissues  of  the  vaginal  portion  with  the  squamous  epithelium  still 
unbroken.  This  view  follows  the  hypothesis  of  Huge  and  Yeit  as  to  the 
deep-seated,  connective-tissue  origin  even  of  papillary  growths,  although 
such  growths  apparently  arise  from  the  squamous  epithelial  surface  of 
the  portio  vaginalis,  (ii.)  As  a  shallow  ulcer  on  the  surface  of  the  vaginal 
portion,  a  feature  due  to  the  origin  of  the  new  growth  in  the  most  super- 
ficial part  of  the  connective  tissue  under  the  pavement  epithelium  or 
in  the  "erosion,"  follicular  or  otherwise,  which  in  structure  is  a  new 
growth,  and  is  capable,  according  to  the  hypothesis,  of  assuming  malignant 
characters.  The  process  thus  originating  attacks  by  preference  only  the 
surface  of  the  vaginal  portion,  and  extends  towards  the  vagina ;  never 
upwards  through  the  os  externum,  (iii.)  As  a  nodule  or  nodules  within 
the  OS  externum,  and  underlying  the  mucous  membrane,  through  which 
the  minute  malignant  growth  ultimately  penetrates,  producing  necrosis. 
This  form  is  the  clinical  result  of  the  malignant  process  which  starts  in 
the  connective  tissue  of  the  walls  of  the  cervix  just  under  the  mucosa, 


652  SYSTEM   OF  GYNAECOLOGY 

and  it  spreads  readily  along  the  cervical  canal,  but  not  downwards 
beyond  the  os  externum. 

This  is  all  so  plain  and  obvious  that  the  student  might  be  disposed 
to  conclude  that  the  pathology  of  cancer  of  the  vaginal  portion  and 
cervix  is  one  of  the  simplest  chapters  in  gynaecology ;  whereas,  in 
fact,  there  are  few  subjects  of  which  the  details  are  more  complicated  and 
more  exasperating ;  more  elusive  of  all  attempts  to  grasp  and  co-ordinate 
them.  To  complete  the  theoretical  study  it  would  be  desirable  to  ob- 
tain some  cases,  beyond  cavil  or  reasonable  dispute,  so  early  in  their 
development  as  to  stamp  them  as  of  the  squamous-celled  portio,  of  the 
"  erosion,"  or  of  the  cervical  mucosa.  The  cases  referred  to  in  Ruge 
and  Yeit's  earliest  work  are  not,  however,  much  more  conclusive  than 
the  later  observations  of  Abel  and  Landau  on  the  corporeal  endometrium. 
Chronic  endometritic  tissue  changes  were  found  by  them,  on  microscopic 
examination  of  the  uterus  removed  by  vaginal  hysterectomy  on  account  of 
epithelioma  of  the  cervix,  to  be  sarcomatous  in  character ;  a  conclusion 
proved  to  be  erroneous  by  subsequent  observers. 

During  the  last  sixteen  years  I  have  endeavoured  to  examine  cancer 
cases  with  some  precision  and,  keeping  these  theoretic  opinions  in 
mind  as  they  were  published,  I  have  sought  for  early  cases  even  when 
symptoms  did  not  suggest  the  presence  of  malignant  disease  ;  but  I  have 
never  seen  a  case  of  flat  ulcer,  of  papillary  growth  of  the  portio  vaginalis, 
or  of  carcinoma  of  the  cervix,  in  which  the  os  externum  was  not  involved. 
Some  of  the  cases  have  been  in  the  earliest  clinical  stage,  with  only  a 
very  small  amount  of  friable  material  outside  or  inside  the  os  uteri ;  and 
in  all  such  cases  the  appearances  on  examination  pointed  to  the  margin 
of  the  OS  externum  —  the  belt  of  transitional  epithelium  —  as  the  site  of 
origin  of  the  growth.  It  is  quite  true  that  Sir  John  Williams,  in  his 
monograph  on  Cancer  of  the  Uterus,  states  a  widely  different  opinion  on 
the  same  ground  of  clinical  observation.  He  says  :  ''  On  looking  through 
these  cases,  we  find  that  cancer  may  begin  at  any  point  of  the  vaginal 
portion  from  the  os  uteri  to  the  vaginal  vault.  It  may  begin  at  more 
than  one  point  —  at  several  close  together  —  as  in  the  first  case,  or  it  may 
originate  at  the  external  orifice  as  in  the  second  and  thiixl  cases,  or  it 
may  commence  from  the  surface  of  a  polypus  growing  from  the  lip  —  it 
may  begin,  in  fact,  on  any  point  of  the  cervix  covered  with  stratified 
epithelium."  Holding  the  opinion  which  he  has  expressed,  that  the 
cancerous  process  always  involves  the  os  externum,  the  present  writer 
must  submit  that  Sir  John  Williams'  description  of  his  material  does 
not  bear  out  his  conclusions.  For  fear  of  being  mistaken  or  appearing 
unfair,  he  has  frequently  gone  over  the  points  of  the  eight  cases  described ; 
in  only  one  case  was  the  os  uteri  uninvaded,  and  that  case,  it  may 
reasonably  be  objected,  would  be  better  described  as  one  of  primary 
epithelioma  of  the  vagina  due  to  the  prolonged  irritation  and  "  insult " 
of  thirteen  years  of  prolapse.  Is  not  the  histology  as  described  also 
that  of  pi'imary  cancer  of  the  vagina  ? 

From   wliat  has  been  said,  it  will  be  inferred  that  my  conclusion 


MALIGNANT  DISEASES   OF   THE    UTERUS  653 

is  that  the  distinction  usually  maintained  between  cancer  of  the  portio 
and  of  the  cervix  is  an  arbitrary  one,  and  one  not  supported  by  the  facts 
of  cases  in  actual  practice. 

Among  others  Leopold  maintained  the  same  opinion.  In  a  discussion 
on  the  diagnosis  of  cancer  of  the  body  of  the  uterus,  he  supported  the 
theory  of  Waldeyer,  Thiersch,  and  others,  that  cancer  can  only  be  defined 
as  an  atypical  epithelial  neoplasm  ;  and  he  endeavoured  to  prove  that  to 
separate  cancer  of  the  portio  from  that  of  the  cervix  is  not  in  accordance 
with  the  facts,  and  is  indeed  impossible.  "Carcinoma  of  the  uterus 
occurs  most  frequently  below  the  os  internum,  commencing  in  the  epi- 
thelium of  the  portio  vaginalis  ;  seldom  in  that  of  the  mucous  membrane 
of  the  cervix.  A  large  number  of  cases  of  so-called  carcinoma  of  the 
cervix  are  really  cases  of  carcinoma  of  the  portio  vaginalis." 

Modes  of  Extension  of  the  3Ialignant  Growth.  —  Without  trenching 
upon  the  ground  that  must  be  gone  over  in  dealing  with  the  course  and 
symptoms  of  the  disease,  it  may  be  well  here  to  consider  shortly  the 
modes,  including  directions,  in  Avhich  the  disease  spreads  in  its  later  initial 
stages,  and  the  forms  which  it  assumes. 

Epithelioma  of  the  portio  vaginalis,  when  it  takes  the  form  of  flat 
cancroid  or  ulcer,  spreads  impartially  upwards  and  downwards.  The 
shallow  ulceration  doAvnwards  is  most  apparent  comparatively  early,  be- 
cause the  lip  affected  long  retains  its  shape,  however  it  may  change  in 
size  and  in  colour ;  but  any  firm  manipulation  of  the  affected  cervical 
area,  such  as  the  application  of  a  sharp  curette,  at  once  reveals  the 
extent  of  the  invasion.  I  have  before  me  microscopic  preparations  of 
tissue  taken  from  the  clear-cut  margin  of  a  shallow  epitheliomatous 
ulcer  where  it  had  just  reached  the  vaginal  vault  in  front.  There  is 
healthy  tissue  at  one  end  of  the  section,  and  cancerous  tissue  at  the 
other.  The  surface  of  the  ulcer  was  clean  looking,  and  the  whole 
process  seemed  superficial,  but  the  cervical  canal  was  excavated  into  a 
wide  crater,  and  the  whole  uterus  w^as  fixed  by  infiltration  of  the  para- 
metrium. The  same  processes  are  often  seen  in  still  earlier  stages  in  the 
same  relative  advancement;  it  is  purely  a  question  of  stage  in  the 
progress  of  the  disease.  The  superficial  ulcer  which  destroys  the  surface 
of  the  portio  vaginalis,  the  area  of  soft  squamous  epithelium,  does  not 
seem  readily  to  invade  the  region  of  the  more  cornified  epidermis  of  the 
vagina.  The  tissues  encountered  at  the  line  of  transition  of  the  epithe- 
lium seem  to  exercise  a  certain  retarding  influence. 

At  the  external  os  the  process  of  necrosis,  as  a  rule,  destroys  the  mu- 
cous lining  ra|)i(lly,  and  penetrates  more  or  less  profoundly  the  muscular 
tissue  of  the  vaginal  portion,  although  the  muscular  tissue  offers  greater 
resistance  to  invasion  than  does  the  mucosa.  But  beyond  the  os  ex- 
ternum the  anucous  membrane  disappears  at  a  more  rapid  rate  than  the 
muscular  and  fibrous  tissue  arranged  round  the  os,  and  consequently, 
even  comparatively  late,  there  may  be  a  relative  narrowness  and  firm- 
ness of  the  parts  representing  the  original  os  externum.  The  process  of 
ulceration  continues,  creating  a  sort  of  funnel-shaped  cavity  in  place  of 


654  SYSTEM   OF  GYNECOLOGY 

the  normal  cervical  canal,  and  ultimately  reaches  the  neighbourhood  of 
the  OS  internum.  Here,  again,  there  is  a  comparative  arrest  of  the 
process  oi  necrosis,  only  more  marked  than  that  Avhich  is  found  at  the 
junction  of  the  vaginal  portion  and  vagina,  or  even  at  the  external  os. 
In  not  a  few  cases  the  resistance  to  the  ulcerative  process  is  so  great 
that  considerable  hypertrophy  both  of  epithelial  and  parenchymatous 
elements  may  result.  This  hypertrophy  in  post-climacteric  cases  some- 
times produces  a  complete  closure  of  the  os  internum,  bringing  about 
the  condition  of  hydrometra  which,  probably  by  bacterial  invasion, 
ultimately  becomes  pyometra ;  by  no  means  a  rare  complication  of  post- 
climacteric cancer  of  the  cervix. 

In  the  papillary  form  of  epithelioma  of  the  vaginal  portion  the 
disease  begins  on  the  margin  of  the  external  os.  The  earliest  de- 
velopment of  the  tumour  which  ever  came  under  my  notice  was  that 
of  a  small  growth  with  the  characters  of  cauliflower  excrescence.  It 
was  growing  from  the  margin  of  the  os  externum,  and  the  cervical 
tissue  itself  did  not  appear  to  be  invaded.  Considering  all  the  circum- 
stances of  the  case,  the  operation  of  total  extirpation  was  recommended 
and  performed,  and  it  was  found  on  incision  at  the  external  os  that 
the  cervical  tissue  was  invaded  nearly  symmetrically  all  round,  and  the 
uterus,  as  a  museum  specimen  at  the  present  time,  shows  a  distinct 
funnel-shaped  excavation  where  the  soft  papillary  growth  originally  ex- 
isted. It  is  alleged  in  several  manuals  and  monographs  which  I  have 
consulted,  that  the  papillary  form  of  epithelioma  does  not  readily  in- 
vade the  tissues  of  the  cervix  uteri,  but  causes  early  infiltration  of  the 
parametric  connective  tissue.  The  first  time  that  I  witnessed  an  opera- 
tion upon  a  uterus  affected  with  cauliflower  growth  was  in  the  Vienna 
Hospital,  over  twenty  years  ago,  when  Carl  Braun  operated  by  means 
of  the  galvanic  cautery.  In  that  case  an  opening  was  made  into 
Douglas'  space;  and  since,  then  I  have  more  than  once  had  the  same 
experience  of  opening  Douglas'  space  on  making  the  first  rapid  incisions 
with  suitable  scissors  for  the  removal  of  the  mass  of  cauliflower  growth 
as  the  first  step  in  extirpation  of  the  uterus.  Such  an  experience 
implies  that  more  than  the  vaginal  portion  of  the  uterus  was  invaded 
Vjy  the  cancerous  growth  during  the  formation  of  the  cauliflower  mass 
which  filled  the  vagina,  and  in  each  case,  on  completion  of  the  operation, 
it  was  found  that  the  amputation  had  been  made  a  little  way  below  the 
internal  os.  In  every  case  of  cauliflower  excrescence,  even  when  the 
mass  in  the  vagina  was  enormously  large,  the  uterus  itself  was  found 
to  be  movable,  and  extirpation  was  considered  feasible.  So  far,  then, 
as  the  spread  of  the  disease  is  concerned,  in  a  case  of  papillary 
epithelioma  it  may  be  confidently  alleged  that  invasion  of  the  cervix  is 
early  and  constant,  and  that  infiltration  of  the  parametritic  connective 
tissue  comes  comparatively  late. 

When  invasion  of  the  parametritic  tissue  does  occur  in  cancer  of  the 
vaginal  portion  or  cervix,  the  areas  first  affected  are  almost  invariably 
ill  tlio  saf'j'o-nterine  folds;  not  in  the  broad  ligaments,  as  one  sees  so 


MALIGNANT  DISEASES   OF   THE    UTERUS  655 

often  asserted.  It  is  wonderful  how  distinctly  the  extent  of  this  inva- 
sion may  be  made  out  in  the  examination  of  a  doubtful  case.  "When 
considerable  ulceration  has  occurred,  and  especially  if  there  have  been 
early  infection  of  the  uterus  with  saprogenetic  organisms  which  pro- 
duce an  offensive  odour,  no  decision  as  to  operation  or  prognosis  should 
be  given  without  a  careful  exploration  of  the  pelvis  per  rectum.  This 
can  only  be  done  efficiently  after  the  bowels  have  been  properly  pre- 
pared, and  the  patient  has  been  put  under  an  anaesthetic.  It  is  then 
possible  to  make  out  with  marvellous  distinctness  the  position  and  size 
of  the  various  parts  of  the  uterus  and  its  relations ;  and  if  the  slightest 
infiltration  have  occurred  in  a  sacro-uterine  fold  or  anywhere  else,  it 
can  hardly  be  missed.  The  condition  of  one  or  other  fold  —  and  it  is 
always  one  or  other  in  such  a  case,  never  both  —  is  often  that  of  a 
curved  line  of  irregular  nodules.  These  swellings  are  rightly  assumed 
to  be  produced  by  glandular  infiltration  and  enlargements.  Repeatedly, 
in  operating  in  rather  advanced  cases,  I  have  gouged  out  of  the  para- 
metric tissues  small  infiltrated  glands,  like  the  smallest  of  those  that 
we  are  familiar  with  in  dissecting  the  axilla  in  the  operation  for  mam- 
mary cancer.  It  is  the  gradual  development  of  this  invasion  of  the 
sacro-uterine  folds,  more  than  any  other  individual  facts  in  the  case, 
which  brings  about  fixation  of  the  uterus. 

The  clinical  form  of  the  disease  at  a  comparatively  early  stage, 
sometimes  called  mushroom  growth,  arises  from  hypertrophy  of  the 
parenchyma  of  the  cervix  with  softening  owing  to  infiltration  of  can- 
cerous elements.  It  is  almost  always  a  carcinoma  of  the  cer^dx  uteri, 
and  its  site  of  origin  is  within  the  os  externum.  It  marks  a  stage  of 
the  development  of  the  new  growth  at  which  the  uterus  is  almost  in- 
variably movable. 

The  later  stages  of  the  progress  of  the  vaginal  portion  or  cervix  may 
be  more  suitably  taken  under  the  symptoms  and  progress  of  the  disease 
than  in  treating  of  the  pathological  anatomy. 

Etiology.  —  To  know  the  causes  of  things  is  said  to  be  the  chief  aim 
of  philosophy;  and  as  applied  to  medicine  in  no  portion  of  the  field  has 
greater  industry  and  intellectual  effort  been  expended  with  less  satis- 
factory returns  than  in  endeavouring  to  get  at  the  causes  of  malignant 
disease  of  the  uterus.  The  object  sought  for  has  been  some  clue  to  the 
intimate  nature  of  cancer  with  a  view  to  prevention  and  rational  treat- 
ment. This  is  a  pursuit  for  the  general  pathologist,  not  for  a  specialist 
in  diseases  of  women,  but  there  are  well-ascertained  facts  with  regard 
to  malignant  disease  as  it  affects  the  female  sex  Avhieh  give  the  study 
of  the  etiology  a  special  interest  to  the  gj-naecologist. 

First,  as  to  frequency  of  occurrence,  malignant  disease  affects  the 
uterus  in  a  very  large  proportion  of  all  tlie  cases  observed ;  and  to  this 
preference  is  due  the  fact,  well  established  by  statistics,  that  women 
are  much  more  liable  to  cancer  than  men. 

Such  statistics  are  easily  available  for  reference,  and  need  not  be 
quoted  in  detail.     The  older  compilations  of  figures  may  be  found  in 


656  SYSTEM  OF  GYNAECOLOGY 

Gusserow's  classical  work  on  the  'New  Groioths  of  the  Uterus,  and  some 
others  will  be  referred  to  in  the  sequel.  Statistics  proved  before  Simpson's 
■work  that  in  England,  between  thirty  and  forty  years  ago,  about  twice  as 
many  women  as  men  died  of  cancer.  Simpson  showed  that  malignant 
disease  was  about  equal  in  the  sexes  at  or  about  the  age  of  fifteen ;  and 
from  this  period  of  life  the  difference  became  more  marked  until  between 
the  ages  of  45  and  55,  when  the  proportion  of  women  to  men  affected 
was  as  31^  to  1 ;  and  then  it  began  to  approach  a  more  equal  distribution. 

When  we  come  to  the  particulars  of  sex  and  organ  attacked,  we  hnd 
that  cancer  of  the  uterus  takes  the  most  conspicuous  place.  Schroeder 
found  that  of  19,666  women  who  died  of  cancer,  6548  were  affected  with 
carcinoma  of  the  uterus. 

For  the  Paris  hospitals  the  figures  as  given  by  Picot  lead  to  much 
the  same  conclusion  with  regard  to  the  proportion  of  men  and  women 
affected ;  and  Picot  brings  out  the  fact  that  in  100  cases  of  cancer  51 
were  malignant  disease  of  the  uterus  or  mamma,  and  that  there  were 
inore  than  three  times  as  many  cases  of  the  former  as  of  the  latter. 

Similar  results  were  brought  out  by  E.  Wagner  on  investigation  of 
the  post-mortem  examinations  in  Vienna,  Prague,  and  Leipzig. 

In  this  country,  more  recently.  Sir  Spencer  Wells  again  analysed 
the  statistics  and  obtained  results,  as  compared  with  Simpson's,  which 
suggested  an  increase  in  the  frequency  of  malignant  disease,  with  a  still 
higher  ratio  of  women  to  men.  Leaving  aside  these  general  results  from 
the  examination  of  vast  numbers  (32)  of  cases,  we  must  look  to  details 
for  assistance.  Oskar  Miiller  analysed  in  great  detail  577  cases  of  can- 
cer of  the  uterus  which  were  observed  at  Gusserow's  clinic,  and  brought 
out  some  very  striking  facts  which  suggest  more  definite  conclusions. 

A  defect  observable  in  all  these  analyses,  one  which  greatly  lessens 
their  value  when  looked  to  for  practical  hints,  is  the  grouping  together 
of  all  forms  of  malignant  disease  of  the  uterus.  But,  so  far  as  causation 
is  concerned,  cancer  of  the  portio  vaginalis  and  cervix  may  be  looked 
upon  as  a  disease  quite  distinct  from  carcinoma  of  the  body  of  the  u.te- 
rus,  or  sarcoma  in  either  body  or  cervix.  Carcinoma  of  the  body  is  a 
comparatively  rare  disease  found  under  conditions  strikingly  different 
from  epithelioma  of  the  portio.  It  may  be  put  down  for  the  present  at 
about  2  to  3  per  cent  of  all  cases  of  carcinoma  of  the  uterus.  The  pro- 
portion of  cases  of  sarcoma  is  at  present  an  unknown  quantity.  The 
cases  are  practically  included  in  the  figures  for  cancer  of  the  body,  and 
therefore  they  amount  to  a  fraction  of  the  3  per  cent. 

Taking  the  figures  which  have  l)een  compiled  as  we  find  them,  and 
applying  a  logical  method  of  induction  by  looking  for  some  constant 
point  of  agreement  amidst  the  bewildering,  diiferences  presented  in  the 
analysis  of  a  large  number  of  cases,  we  are  struck  with  the  agreement 
within  limits  as  to  the  age  of  the  patients.  The  great  majority  are 
women  past  the  middle  period  of  their  sexual  life,  if  that  l)e  reckoned  as 
from  15  to  45,  and  many  are  Ijeyond  it  —  past  the  mcmopause.  Gus- 
serow  puts  togctlx-r  tlu;  figures  of  certain  writers,  whom  he  mentions, 


MALIGNANT  DISEASES    OF   THE    UTERUS  657 

and  reaches  a  total  of  3385  cases  of  cancer  of  the  uterus.  Of  these 
women  only  two  were  under  20  years  of  age ;  and  we  may  fairly  assume 
that  these  were  cases  of  sarcoma.  Of  the  Avhole,  1169  cases  occurred  be- 
tween 40  and  50,  and  856  between  50  and  60.  "When  we  make  allowance 
for  the  fact  that  the  number  of  living  Avomen  rapidly  decreases  from 
decade  to  decade  of  their  age,  we  see  that  the  number  of  cases  between 
40  and  60  forms  a  very  large  fraction  of  the  whole. 

Oskar  Mtiller  found,  in  the  577  cases  which  formed  the  subject 
material  of  his  contribution,  more  than  one-third  of  the  patients  were 
under  40  years  of  age,  and  in  no  case  was  the  age  under  20. 

In  100  consecutive  cases  in  the  out-patient  department  of  the 
Manchester  Southern  Hospital  I  find  77  cases  sufficiently  detailed  to 
be  safe  for  reference :  of  these  1  was  under  30,  23  were  between  30 
and  40,  28  between  40  and  50,  21  between  50  and  60,  and  4  between 
60  and  70.     There  was  no  case  over  70. 

Of  the  54  in-patients  admitted  to  the  Cancer  Hospital  connected 
with  Owens  College  since  its  opening,  2  were  under  30,  11  between  30 
and  40,  28  between  40  and  50,  11  between  50  and  60,  1  between  60 
and  70,  and  1  over  70.  There  was  only  1  case  of  cancer  of  the  body 
among  these,  and  one  case  of  sarcoma  of  the  uterus. 

We  may  consider  the  influence  of  age  as  completely  demonstrated: 
50  years  is  the  age  at  or  about  which  the  climax  is  reached.  Age 
suggests  lowered  vitality  and  tendency  to  degeneration,  but  specula- 
tions in  this  direction  have  led  to  nothing.  The  deteriorated  vitality 
of  the  tissues  is  common  to  all  women  of  the  same  age  whether  cancer 
is  to  appear  or  not. 

NarroAving  down  from  age  to  race,  we  find  a  suggestive  fact.  It 
may  be  considered  as  proved  beyond  doubt  that  cancer  of  the  uterus  is 
much  less  common  among  the  negro  races,  and  even  among  Asiatics, 
than  it  is  among  the  white  races.  This  fact  seems  to  imply  that 
persons  more  highly  organised  intellectually  and  morally  are  rather 
subject  to  this  scourge  than  those  who  are  more  callous  or  less  intel- 
lectual or  imaginative. 

If  we  now  come  within  still  narrower  limits,  from  race  to  class,  we 
meet  with  a  still  more  striking  fact.  All  observers  are  agreed  that 
cancer  of  the  uterus  (without  distinguishing  the  cervix,  which  would 
make  the  exceptions  still  fewer)  is  most  frequently  met  with  in  the 
lower  ranks  of  the  people  of  all  countries.  So  marked  is  the  difference 
of  incidence,  that  it  might  be  reasonably  affirmed  that  if  we  could  place 
all  the  lower  orders  who  suffer  from  privation  and  dei)ressing  environ- 
ment for  a  generation  or  two  in  the  position  of  the  more  favoured  we 
should  stamp  out  cancer.  In  his  analysis  of  577  cases  Oskar  Miiller 
found  that  the  patients  were  almost  exclusively  of  the  labouring  class. 
My  experience  is  that  cancer  of  the  portio  and  cervix  occurs  only 
among  the  working  classes ;  the  apparent  exceptions  are  so  few  that 
they  are  hardly  worth  discussing.  This  remark  applies  to  private  as 
well  as  to  hospital  patients. 

2u 


658  SYSTEM  OF  GYNECOLOGY 

Keeping  in  view  age  and  class,  we  proceed  still  furtlier  to  eliminate 
irrelevant  points,  and  we  find  tliat  child-bearing  has  some  relationship 
to  the  causes  of  cancer  of  the  portio  and  cervix.  JSTulliparous  women 
are  almost  immune.  Winckel  {h^^  puts  his  experience  on  this  point 
very  concisely  :  '"  The  large  majority  of  women  with  uterine  cancer  are 
married.  Of  my  patients  only  1-7  per  cent  were  unmarried,  and  two- 
thirds  of  these  had  given  birth  to  one  or  more  children." 

In  the  analysis  of  100  consecutive  malignant  cases  occurring  in 
my  hospital  practice  there  is  only  one  unmarried  woman  (aged  52), 
and  she  was  suffering  from  sarcoma.  Seventy  women,  of  whose  cases 
the  record  is  sufficiently  full  for  the  present  purpose,  had  borne  412 
children,  and  had  lost  of  these  219.  The  total  number  of  abortions 
of  the  70  was  68.  Thus  the  average  number  of  children  was  5-8,  and 
the  average  loss  by  death  in  their  families  was  3-1.  The  average  of 
abortion  was  nearly  one  for  each.  One  woman  had  borne  eight  times, 
and  when  she  came  under  treatment,  at  the  age  of  38,  she  had  only  one 
child  left.  Another  had  borne  six,  and  had  aborted  twice :  she  came 
under  treatment  at  the  age  of  40,  and  she  had  then  only  three  left. 
Another  had  given  birth  to  seventeen  living  children,  and  at  43  she 
had  seven  remaining.  One  had  a  record  of  thirteen  children  and  two 
abortions ;  at  40  she  had  only  four  living.  One  had  been  the  mother 
of  three,  and  at  35,  Avhen  she  underwent  the  operation  of  total  extirpa- 
tion, she  had  none.  Other  examples  are :  at  the  age  of  42,  ten  children, 
six  living,  no  abortions ;  at  45,  eleven  children,  seven  living,  no  abor- 
tions ;  at  40,  seven  children,  four  living,  two  abortions ;  at  45,  ten  chil- 
dren, four  living,  no  abortions ;  at  48,  seven  children,  one  living,  five 
abortions  ;  at  58,  nine  children,  three  living,  three  abortions ;  and  so  on. 
On  the  other  hand,  there  is  one  woman  of  33,  with  all  her  children  liv- 
ing, five  in  number ;  one  of  52  with  her  family  of  eight  all  living ;  and 
another  of  47  with  her  three  children  still  living.  There  was  not  a 
barren  woman  amongst  them.  These  illustrative  details  as  to  loss  of 
children  are  given  here  to  obviate  repetition ;  they  will  be  discussed 
hereafter. 

The  highest  proportion  of  nulliparae  affected  with  cancer  of  the 
uterus  which  I  have  seen  mentioned  is  that  found  by  Oskar  Miiller ; 
namely,  5-3  jjer  cent.  The  number  of  cases  of  cancer  of  the  body  of 
the  uterus  is  not  deducted. 

When  we  follow  such  suggestions  as  possible  causal  relations  be- 
tween cancer  of  the  uterus  and  constitution,  temperament,  occupation, 
previous  illnesses  not  connected  with  infection  or  traumatism  of  the 
sexual  organs,  anomalies  of  menstruation,  sexual  excess,  and  such  like, 
we  can  find  no  trace  of  a  constant  factor. 

What  then  about  heredity,  which  has  taken  such  hold  upon  the 
popular  imagination  ?  In  reference  to  cancer  of  the  uterus  it  appears 
to  1)6  a  factor  of  little  etiological  importance.  In  Oskar  Midler's  analy- 
sis of  Gusserow's  later  cases  it  hardly  ai)])ears.  Gusserow  collected  1203 
cases,  incliidiiig  his  earlier  material,  and  found  only  90,  or  7'8  per  cent, 


MALIGNANT  DISEASES   OF   THE    UTERUS  659 

in  which  cancer  might  have  been  produced,  among  other  causes,  by 
hereditary  tendency.  Picot  found  a  hereditary  predisposition  in  13  per 
cent  of  cancer  of  all  organs.  But  it  should  be  remembered  that  to  trace 
heredity  among  the  class  of  women  usually  affected  with  cancer  is  a 
difficult  process.  Genealogy  is  not  a  strong  feature  in  the  acquirements 
of  their  class ;  it  is  often  very  difficult  to  get  with  precision  the  most 
elementary  facts  in  the  history  of  the  individual  patient  herself. 
Heredity,  at  any  rate,  has  not  been  shown  to  be  an  important  factor 
in  the  production  of  cancer  of  the  uterus. 

Setting  aside  irrelevant  and  questionable  evidence  as  to  causation, 
we  find  some  striking  points  which  are  fairly  constant :  (i.)  The  race, 
one  highly  developed,  although  the  class  attacked  does  not  consist  of  the 
highest  specimens  of  their  race  ;  (ii.)  the  social  class  whose  lives  are  the 
most  laborious,  monotonous,  and  careworn  of  their  community ;  (iii.) 
the  domestic  relationships  of  marriage  and  maternity ;  and  (iv.),  age,  a  cer- 
tain limited  period  of  the  individual  life.  The  age  is  that  of  the  decay 
or  extinction  of  the  functional  activity  of  the  sexual  organs,  and  of 
diminishing  vitality  of  the  tissues  in  general.  The  domestic  circum- 
stances and  the  class  of  the  sufferers  imply  a  vast  amount  of  unhappy 
experience  of  life. 

On  the  physical  side  there  is  the  constant  drain  on  the  constitution 
of  frequent  pregnancy  and  lactation,  sometimes  both  combined  at  the 
same  time ;  for  many  of  these  women  go  on  suckling  their  children 
partly  for  the  sake  of  economy,  partly  because  they  believe  lactation 
prevents  conception.  Parturition  means  injury  to  the  cervix  uteri,  and 
not  unfrequently  still  further  drains  upon  their  strength  by  puerperal 
illness.  There  is  to  be  included  almost  invariably,  also,  irritation 
and  consequent  discharges  from  the  injured  cervix  and  vaginal  portion 
of  chronically  filthy  genitals.  In  addition  there  is  the  loss  of  rest  from 
nursing  sick  children,  and  the  constant  clamour  of  those  who  are  well. 
Many  of  the  women  of  the  class  under  consideration  live  laborious  lives 
in  doing  domestic  work,  or  as  the  breadwinners  of  ailing,  lazy,  or  dis- 
sipated husbands.  We  must  also  keep  in  mind  the  chronic  deficiency 
of  nourishing  food  and  of  suitable  clothing,  and  that  many  live  under 
the  most  insanitary  conditions  of  their  own  making,  which  no  local 
authority  can  avert.  Too  frequently,  also,  bodily  exhaustion  and 
mental  depression  lead  to  the  use  of  bad  alcoholic  stimulants,  and  when 
food  is  not  plentiful  the  line  of  excess  is  easily  reached.  Alcohol  under 
such  conditions  produces  a  chronic  metritis  which  is  quite  characteristic. 

On  the  mental  side  there  is  constant  care  as  to  pecuniary  means, 
worries  from  interrupted  employment,  anxieties  from  the  illnesses  of 
husband  and  children,  and  grief  from  frequent  fatal  termination  of 
illness  in  both  young  and  old.  Eighteen  per  cent  of  the  cases  to  which 
I  have  referred  as  illustrating  loss  of  children  Avere  widows.  Add  to  all 
this  the  constant  nmnotimy  of  the  lives  of  such  women  ;  the  lives  of 
the  men  are  by  comparison  interesting  and  free  from  care. 

But,  it  may  be  asked,  What  has  all  this  to  do  with  cancer  of  the 


66o  SyST£J\/   OF  GYNECOLOGY 

cervix  uteri  ?  The  relation  to  physical  and  mental  depression,  com- 
bined with  local  lesions,  is  not  very  remote.  With  some  effects  of 
emotional,  conditions  upon  the  uterus  we  are  quite  familiar.  We  know 
that  violent  emotions  produce  interruptions  of  pregnancy,  and  many 
illustrations  of  minor  injuries  directly  due  to  violent  emotion  might  be 
quoted  if  space  permitted.  It  stands  to  reason,  therefore,  that  the 
griefs  and  smaller  depressing  emotions  —  from  bereavement  by  death  to 
domestic  quarrels  and  insults  —  by  which  the  women  suffer,  and  on  which 
they  brood  without  alleviating  distractions,  may  in  time  produce  serious 
results  by  a  sort  of  integration  of  the  effects  of  emotional  storms  com- 
paratively frequent  and  therefore  little  noted. 

Coming  to  more  definite  details  as  to  factors  modifying  nutrition, 
we  have  also  to  note  the  chronic  irritation  from  lacerations  of  the  cervix 
and  chronic  cervical  catarrh.  IJhi  stimulus,  ibifluxus.  Many  gynaecolo- 
gists have  said  that  they  have  never  obtained  any  evidence  of  a  causal 
relation  between  laceration  of  the  cervix  and  epithelioma.  But  have 
they  not  looked  too  much  to  the  fissure  and  the  cicatrix  ?  A  cervix  that 
has  been  deeply  lacerated  undergoes  very  gradual  changes,  which  show 
that  the  irritation  exists  not  in  the  cicatrix,  but  in  the  whole  of  the 
vaginal  portion ;  and  the  coincidence  of  epithelioma  and  "  multiparous 
OS  "  is  too  frequent  to  be  explained  as  mere  chance. 

There  is  also  a  susi^icious  frequency  of  coincidence  of  malignant 
disease  of  the  cervix  and  a  history  of  gonorrhoeal  infection.  Bumm 
has  made  a  statement  with  which  all  gynaecologists  who  have  paid  special 
attention  to  the  subject  of  gonorrhoea  in  women  must  agree.  "  The  chief 
seat  of  gonorrhoea  in  the  woman  is  the  urethra  and  the  cervix  uteri ;  the 
infection  of  the  cervix  produces  symptoms  and  distress  only  at  the 
beginning ;  when  it  has  once  become  chronic  it  may  continue  for  years 
without  causing  trouble  (Beschwerden)."  Winckel  (56)  may  also  be 
quoted  from  among  many  authors  who  have  given  expression  to  a 
similar  opinion :  ''  It  seems  plausible  that  such  specific  diseases 
(gonorrhfjeal  infection)  favour  the  development  of  carcinoma."  There 
is  also  an  emotional  side  to  this  possible  factor  in  the  causa,tion  of 
cancer.  When  working  at  gonorrhoeal  infection  in  women,  my  experi- 
ence was  that  a  hospital  patient  suffering  from  post-nuptial  infection 
had,  nearly  always,  to  bear  also  the  domestic  trouble  of  a  lazy,  useless, 
or  dissipated  husband.  When  questioned  as  to  the  husband's  occupa- 
tion the  answer  came  with  remarkable  frequency  that  he  was  out  of 
work.  The  cruelty  of  conveying  infection  was  not  at  all  likely  to  be 
an  isolated  injurious  act  in  the  domestic  history  of  such  people. 

The  conclusion  which  the  facts  seem  to  lead  up  to  is  that  cancer 
of  the  vaginal  portion  and  cervix  is  very  largely  a  morbus  miseriw. 
What  the  import  of  the  apparent  exceptions  may  be  I  do  not  profess  to 
understand,  but  it  seems  probable  that  if  the  conclusion  be  in  the  main 
true,  the  exceptions  when  understood  will  support  the  law.  While 
heredity  in  the  individual  is  obscure  or  apparently  feebly  expressed, 
there  may  Ije  in  the  exceptions  the  expression  of  the  hereditary  suffer- 


MALIGNANT  DISEASES   OE  THE    UTERUS  66i 

ings  of  the  class ;  the  comparatively  well-cared-for  individual  of  her 
generation  requiring  comparatively  little  of  a  determining  cause  to  bring 
out  that  which  might  have  appeared  in  the  former  generation,  but  for 
the  absence  of  the  final  determining  local  cause. 

The  hypothesis  of  morbus  miserice  places  cancer  of  the  cervix  in  the 
same  category  as  leprosy  ;  and  by  analogy  we  may  assume  that  cancer 
may  be  banished  by  social  ameliorations  which  will  raise  the  presently 
existing  cancer-producing  class  to  the  higher  level  of  the  presently  exist- 
ing immune,  just  as  the  disappearance  of  the  horrors  in  the  individual 
lives  and  environment  of  past  generations  has  made  leprosy  in  England 
an  historic  disease. 

The  Synij^toms  and  Clinical  Course. — In  the  early  stage  of  cancer  of 
the  vaginal  portion  there  are  no  symptoms  which  could  indicate  to  the 
person  affected  the  presence  of  a  grave  disease.  There  is  nothing  to 
interfere  in  the  slightest  degree  with  the  ordinary  course  of  life ;  and 
even  if  the  woman's  attention  be  attracted  to  certain  trifling  symptoms, 
her  fears  are  not  excited ;  thus  it  is  very  rarely  indeed  that  the  physi- 
cian has  the  opportunity  of  observing  a  case  from  the  earliest  onset 
even  of  the  symptoms.  The  chief  symptoms,  in  the  order  in  which 
they  appear  before  their  relations  are  obscured  by  the  appearance  of 
important  complications,  are  haemorrhage,  a  more  or  less  offensive  vagi- 
nal discharge,  and  pain.  The  haemorrhage  comes  from  the  portion  of 
the  cervix  uteri  affected,  that  is  to  say,  almost  always  from  the  free 
vaginal  surface  at  the  margin  of  the  portio.  It  is  seldom  profuse.  It 
appears  rather  as  an  irregular  slight  hasmorrhagic  discharge  from  the 
genitals  than  as  the  immediate  result  of  traumatism.  The  injury  may 
be  produced  by  straining  in  constipation,  by  sexual  intercourse,  or  by 
some  other  cause  implying  direct  interference  with  the  part  affected. 
In  the  married,  haemorrhage  post-coitum  is  perhaps  the  most  constant 
and  suggestive  ante-climacteric  sign.  The  stimulus  to  the  uterus  result- 
ing from  the  presence  of  the  new  growth  may  be  such  as  to  produce  a 
noticeable  increase  in  the  amount  or  duration  of  menstnuition,  but  this 
is  not  by  any  means  a  constant  feature  at  any  stage  of  the  disease,  and 
its  extent  has  been  probably  much  exaggerated.  Before  the  ulceration 
and  infiltration  have  so  far  advanced  as  to  make  pain  a  noteworthy 
symptom,  a  small  vessel  may  occasionally  give  way,  producing  a  smart 
attack  of  haemorrhage ;  but  the  occurrence  of  any  considerable  or  alarm- 
ing ha3morrhage,  either  by  sudden  profuse  discharge  or  by  prolonged 
slight  metrostaxis,  is  not  an  ordinary  feature  of  the  early  stage  of 
malignant  disease  of  the  uterus. 

In  Avomen  who  have  passed  the  change  of  life  ha?morrbage  is  still 
the  first  symptom  of  the  disease ;  but  then  it  usually  attracts  more  atten- 
tion, and  leads,  upon  the  whole,  to  an  earlier  demand  for  medical  advice : 
yet  still  the  tendency  is  to  waste  time.  However  far  advanced  in  years, 
the  patient  is  apt  at  first  to  be  satisfied  in  her  own  mind  that  men- 
struation has  recurred;  and  there  is  a  deep-rooted  conviction  that 
any   discharge   of   the   nature   of    menstruation   is   beneficial.      Tost- 


662  SYSTEM  OF  GYNAECOLOGY 

climacteric  pudendal  htemorrliage  should  always  suggest  malignant 
disease. 

At  or  about  the  menopause  the  haemorrhage  is  attributed  at  first  to  a 
supposed  irregularity,  or  even  flooding,  characteristic  of  the  change  of  life, 
and  not  implying  any  pathological  departure  from  the  ordinary  health. 

Somewhat  l^ter  in  the  course  of  the  disease  haemorrhage  may  become 
profuse,  and  it  occasionally  continues  in  a  slighter  degree  for  weeks  with- 
out intermission ;  contributing  largely  to  that  condition  which  we  call 
the  cancerous  cachexia. 

The  foul  discharge  is  the  second  characteristic  symptom  of  earl}^ 
malignant  disease  of  the  cervix.  The  discharge  is  at  first  entirely  or 
comparatively  inodorous.  This  is  specially  the  case  in  the  profuse  dis- 
charge from  the  cauliflower  excrescence  before  the  growth  has  been  inter- 
fered with  in  any  way,  either  in  the  digital  examination  of  the  physician, 
or  in  the  use  of  a  syringe  manipulated  by  the  patient  herself.  The  dis- 
charge from  the  cauliflower  excrescence,  even  in  the  early  stage,  is  pro- 
fuse ;  but  it  is  comparatively  thick  and  slimy :  it  is  neither  serous  nor 
matte^3^  In  the  earliest  stage  of  all  it  contains  numerous  white  particles, 
portions  of  the  rapidly  growing  and  necrosing  epithelial  elements.  In 
the  case  of  a  superficially  ulcerating  epithelioma,  or  in  the  early  stage 
of  cancer  of  the  cervix,  the  discharge  is  scanty,  thin,  and  serous ;  but  it 
soon  assumes  its  characteristic  turbid,  dirty  water,  and  repellent  appear- 
ance, and  its  extremely  offensive  odour.  As  a  rule  it  is  a  profuse  dis- 
charge before  it  becomes  a  foul  discharge.  The  discoloration  of  the 
discharge  arises,  no  doubt,  from  minute  extravasations  of  blood,  the  ele- 
ments of  Avhich  become  darkened  and  disintegrated  in  the  serous  fluid, 
and  under  the  chemical  and  bacterial  influences  at  work.  The  offensive 
odour  is  produced  by  the  changes  which  the  serous  fluid  undergoes  in 
oozing  from  the  necrosing  surfaces,  owing  to  the  access  of  air  and  ex- 
ternal filth,  and  to  the  invasion  of  saprogenetic  organisms.  The  modes 
of  infection  by  these  organisms  are  numerous  and  obvious.  There  is 
always  the  possibility  of  an  autogenetic  infection,  as  it  has  been  called, 
by  bacteria  previously  existing  in  the  vagina ;  and  in  the  disease  under 
consideration  there  is  always  easy  access  of  infecting  material  from 
the  external  genitals,  inasmuch  as  it  is  a  disease  of  multiparse,  in  whom 
the  vulva  and  vagina  are  as  a  rule  flabby,  readily  gaping  on  movement  in 
a  recumbent  position,  especially  on  the  side.  There  can  be  little  ques- 
tion also,  that  all  manipulations,  even  those  undertaken  with  antisep- 
tics in  order  to  cleanse  the  parts,  are  capable  of  producing  injuries 
of  the  affected  tissue,  slight  haemorrhages,  and  even  saprogenetic 
inoculation. 

When  a  serous  offensive  discharge  has  once  been  set  up,  it  is  perma- 
nent; and  however  the  haimorrhage,  or  pain,  or  other  symptoms  may  be 
modified  by  treatment,  the  foul  discharge,  except  on  total  extirpation, 
persists  to  the  end.  It  may  be  modified  for  a  time  ])y  antiseptics,  by 
curetting  and  other  direct  treatment,  but  it  is  never  wholly  removed. 

Pain,  as  a  syinpt^jm  of  malignant  disease  of  the  portio  vaginalis  or 


MALIGNANT  DISEASES   OF   THE    UTERUS  663 

cervix  uteri,  comes  on  comparatively  late ;  and  cases  are  met  with  in 
which  the  whole  course  of  the  disease  is  run  without  the  pain  being 
so  severe  as  to  call  for  the  administration  of  sedative  drugs.  It  may 
be  set  down  as  a  rule  that  Avhen  the  patient  at  the  first  interview  men- 
tions pain  as  a  prominent  symptom,  we  may  expect  to  find,  on  physical 
examination,  that  the  disease  is  well  advanced,  and  that  the  uterus  is 
fixed,  or  at  least  in  such  a  condition  as  to  make  thorough  surgical  treat- 
ment impossible  or  useless. 

It  has  been  so  frequently  observed  that  when  there  is  rapid  necrosis 
of  the  vaginal  portion  producing  an  open  cavity  the  pain  is  slight,  that 
we  might  almost  generalise  to  the  extent  of  saying  that  pain  is  in  inverse 
ratio  to  the  amount  of  ulceration. 

When  the  vaginal  portion  alone  is  affected  there  is  no  pain.  The 
onset  of  pain  appears  to  coincide  with  the  invasion  of  the  parametrium, 
and  consequent  interference  with  the  mobility  of  the  uterus.  The  exten- 
sion of  the  cancerous  parametritis  ultimately  causes  pain  of  a  different 
kind  by  pressure  on  nerve  trunks.  This  is  the  origin  of  the  distress- 
ing aching  in  the  groins,  thighs,  and  down  the  legs,  which  is  usually 
the  first  painful  symptom  complained  of. 

When  the  ulceration  reaches  the  vicinity  of  the  os  internum,  or 
somewhat  earlier  when  the  case  is  one  of  the  hard  form  of  cancer  of 
the  cervix,  we  hear  of  a  genuine  uterine  pain.  It  is  the  dull  aching 
in  the  sacral  region  which  now  becomes  persistent.  It  may  have  been 
complained  of  earlier  as  comparatively  slight  at  the  time  when  fixation 
of  the  uterus  was  beginning.  When  pain  is  hypogastric  and  spasmodic 
at  times  there  is  reason  to  suspect  occlusion  of  the  internal  os  and  the 
formation  of  pyometra.  This-is  probably  the  explanation  of  the  inter- 
mittent or  colic-like  character  ascribed  to  the  pain  in  some  cases.  It 
applies  only  to  post-climacteric  cases ;  in  younger  women  the  extension 
of  the  disease  so  as  to  interfere  with  the  lumen  of  the  internal  os,  or  to 
produce  rigidity  of  tissues  in  its  neighbourhood,  must  obviously  pro- 
duce a  characteristic  discomfort  amounting  at  the  menstrual  periods  to 
intense  suffering.  To  pressure  of  infiltration  upon  uterine  nerve,  and 
destruction  of  nerve  tissue  by  ulceration,  must  reasonably  be  attributed 
a  part  of  the  constant  pain  referred  both  to  the  sacral  and  the  hypo- 
gastric regions. 

Later  still  in  the  history  of  the  case  an  element  in  the  pain  is  inter- 
ference with  the  bladder  and  bowel,  or  other  organ  to  which  the  sense 
of  pain  is  referred.  And  among  the  local  causes  of  suffering  Ave  find 
sometimes,  though  not  so  frequently  as  might  be  expected,  an  irrita- 
tion about  the  vulva  from  dermatitis  or  pruritus  produced  by  the 
discharge. 

If  the  patient  live  sufficiently  long  there  is  added  to  her  sufferings 
a  constant  dull,  depressing  pain  from  the  extension  of  the  disease  to 
the  peritoneum.  The  peritonitis  is  rarely  acute,  and  the  pain  is  often 
brought  out  only  by  i^alpatiou  in  the  course  of  examination  or  treatment. 
It  is  a  periuietritis,  and  it  seldom  extends  beyond  the  pelvis  except  as 


664  SYSTEM  OF  GYXyECOLOGY 

a  final  lesion  due  to  some  accident  or  rupture  which  makes  it  general 
and  rapidly  fatal. 

Perhaps  the  explanation  of  the  low  form  of  the  peritonitis  and  its 
comparative  painlessness  is  that  it  is  always  a  late  complication.  The 
patient  is  then  both  anaemic  and  sapra^mic,  and  from  this  physical  con- 
dition arises  largely  the  characteristic  hebetude  and  apathy.  Besides, 
the  uterus  at  this  stage  has  been  long  fixed  by  the  infiltration  which 
also  interferes  with  the  ureters,  and  the  resulting  uraemia  must  add  its 
contribution  to  the  production  of  anaesthesia. 

By  the  time  pain  has  come  on  and  the  uterus  is  fixed  we  find  another 
symptom  which,  in  my  experience,  is  constant;  this  is  nocturnal  rise 
of  temperature.  The  temperature  may  be  normal  or  subnormal  in  the 
morning,  but  it  rises  to  100°  or  a  little  higher  at  night ;  and  later  in  the 
course  of  the  disease  there  may  be  sudden  temporary  elevations  to  a 
much  greater  degree.  The  causes  appear  to  be  —  (i.)  the  parametritis, 
and  in  this  respect  it  is  much  as  we  find  it  in  a  chronic  inflammation  of 
the  circumuterine  tissue  without  abscess  formation  ;  and  (ii.)  a  certain 
amount  of  sapraemia  from  absorption  at  the  seat  of  ulceration.  When 
much  loose  necrosed  tissue  prevents  the  free  flow  of  the  serous  discharge, 
if  this  friable  substance  be  removed  by  the  sharp  curette,  and  a  moder- 
ately strong  solution  of  zinc  chloride  be  applied  by  means  of  a  tampon 
of  lint  packed  into  the  cavity,  the  temperature  falls  for  a  few  days  if 
there  be  not  much  cellulitis ;  but  when  the  uterus  is  involved  in  a  pelvic 
mass,  the  operation  produces  little  or  no  impression  upon  the  tempera- 
ture. The  septic  temperature  can  be  removed  temporarily  with  its 
cause ;  the  parametritic  temperature  remains  constant. 

The  absence  of  symptoms  produced  by  sepsis,  even  of  pyrexia,  is 
remarkable,  considering  the  foulness  of  the  ulcerating  cavity.  It  de- 
pends, in  all  probability,  upon  the  fact  that  in  the  invasion  of  the  tissues 
a  stratum  of  non-infective  infiltration  precedes  even  the  deepest  layer 
which  saprogenetic  bacteria  have  reached ;  and  by  this  advanced  stratum 
both  blood-vessels  and  lymphatics  are  rendered  more  or.  less  incapable 
of  taking  up  and  conveying  the  soluble  poison.  Hence  also,  perhaps, 
the  comparative  rarity  of  metastasis  from  uterine  cancer.  The  freedom 
with  which  the  fluid  products  of  necrosis  of  uterine  tissues  can  escape 
no  doubt  also  contributes  to  the  same  result. 

Among  the  more  general  symptoms  of  cancer  of  the  uterus  must  lie 
mentioned  the  effects  of  the  disease  upon  the  digestive  organs,  which 
are  almost  constant.  The  most  striking  fact  in  this  group  of  symptoms 
is  the  early  occurrence  of  anorexia  in  almost  every  case  of  the  disease; ; 
how  it  arises  has  not  been  explained.  It  is  obviously  not  from  any  direct 
effect  upon  the  intestines.  Later  in  the  progress  of  the  disease  it  may 
be  associated  to  some  extent  with  the  sapranuia  wliich  exists  during 
ulceration,  even  if  the  retention  of  debris  and  fluid  be  slight ;  it  certainly 
is  not  caused  by  the  anM;mia,  which  comes  later  in  consequence  of  the 
serous  discharges  and  haemorrhage.  At  a  more  advanced  stage  we  find 
that  changes  affecting  the  digestive  organs  occur  as  the  result  of  pressure ; 


MALIGNANT  DISEASES    OF  THE    UTERUS  665 

this  is  when  the  disease  has  made  such  progress  as  to  produce  a  certain 
amount  of  pelvic  peritonitis,  or  constipation,  by  the  mere  mechanical 
pressure  of  the  enlarged  uterus  or  mass  of  parametritic  exudation  upon 
the  rectum  or  the  lower  part  of  the  sigmoid  flexure.  In  this  interference 
with  the  functions  of  the  intestines  there  are  rarely  any  symptoms 
approaching  in  severity  those  which  mark  the  tendency  to  obstruction, 
as  observed  in  cancer  of  the  bowel  itself,  or  in  pressure  of  the  mass  of 
tumour  on  the  rectum  in  pelvic  hematocele.  There  is  a  certain  amount 
of  pressure  and  a  certain  amount  of  paresis ;  and  these  factors  alone, 
combined  Avith  the  loss  of  flesh,  produce  a  total  result  which  is  fairly 
characteristic;  there  are  abdominal  tumidity  and  softness,  and  we  may 
even  watch  the  peristaltic  action  almost  as  clearly  as  in  obstruction  of 
the  bowel,  partial  or  complete,  from  intestinal  cancer. 

Vomiting  may  occur  comparatively  early,  long  before  a  mechanical 
cause  for  it  exists.  It  is  not,  however,  a  constant  symptom  until  an 
advanced  stage  of  the  disease.  In  early  anorexia  it  may  be  produced 
by  injudiciously  zealous  feeding  to  keep  up  the  strength  ;  by  unsuitable 
food  and  medicines,  or  as  the  result  of  idiosyncras}'.  Vomiting  is  an 
important  factor  in  these  cases,  but  not  an  important  symptom. 

Another  member  of  this  group  of  symptoms  is  irregular  diarrhoea. 
As  a  consequence  of  the  bowel  irritation  produced  by  the  development  of 
the  disease,  we  occasionally  find,  not  extreme  constipation  or  partial  ob- 
struction, but  painful  attacks,  with  frequent  mucous  motions,  lasting  for 
several  days,  and  amounting  to  diarrhoea.  Diarrhoea  is  a  symptom  Avhich 
we  find  at  some  stage  of  several  diseases  primarily  affecting  the  internal 
female  sexual  organs,  and  involving  loss  of  tone  of  the  muscular  tissue 
of  the  lower  bowel.  Such  is  occasionally  the  case  late  in  perimetritis,  for 
example,  and  in  other  conditions  besides  cancer.  "We  frequently  find 
this  symptom  as  a  result  of  inflammation  in  pelvic  abscess ;  not  in  the 
early  stage  of  the  parametritis,  but  in  the  chronic  stage,  when  an  abscess 
exists,  and  is  burrowing  towards  the  intestine,  and  causing  a  certain 
amount  of  pressure  on  it  with  softening  of  its  tissues.  In  such  a  condi- 
tion of  the  intestine,  when  it  is  to  a  certain  extent  softened,  inflammation 
of  the  lining  is  indicated  by  the  occurrence  of  comparatively  small  and 
frequent  motions,  containing  a  large  amount  of  serum  and  mucus.  In  the 
course  of  cancer  of  the  uterus  there  is  an  analogous  condition,  producing  a 
similar  form  of  diarrhoea  which,  however,  is  less  constant  and  continuous. 

With  regard  to  the  urinary  organs  the  symptoms  in  the  earlier  stages 
are  not  appreciable,  whereas  in  the  later  stages  much  distress  is  almost  a 
constant  element  in  the  case.  In  the  early  stage  of  cancer  we  may  be 
unable  to  discover  any  bladder  symptoms  at  all ;  later,  when  circum- 
uterine  structures  are  breaking  down,  the  ulceration  spreads  towards 
the  bladder  more  frequently  than  towards  the  bowel.  Long  before  the 
septum  between  the  utero-vaginal  canal  and  the  bladder  is  broken  down, 
there  is  cancerous  cellulitis  affecting  the  loose  tissue  between  the  uterus 
and  bladder,  and  causing  irritability  of  the  bladder  and  frequent  micturi- 
tion.    Later  still,  on  making  a  careful  examination  in  such  a  case,  with 


666  SYSTE^f  OF  GYNAECOLOGY 

the  aid  of  a  bladder  sound,  we  find  a  suggestion  of  irregularity  and  harden- 
ing of  the  mucous  lining  of  the  bladder  itself.  Invasion  is  now  sufficiently 
far  advanced  to  produce  vesical  catarrh.  Yet  this  is  not  the  principal 
urinary  trouble  associated  with  cancer  of  the  uterus.  The  principal  trouble 
affecting  the  urinary  organs  arises  from  interference  with  the  ureter,  not 
with  the  bladder  itself  directly,  or  with  the  urethra.  As  the  cancerous 
parametritis  extends  outwards  in  the  broad  ligament,  the  uterus  becomes 
fixed.  Owing  to  the  position  of  the  ureters  they  are  very  liable  to  be  sub- 
jected to  pressure.  The  disease  at  first  may  be  unilateral,  or  it  may  spread 
almost  equally  on  both  sides,  and  consequently  the  pressure  may  be  on  one 
ureter  or  both.  Now  the  ureter  in  this  cancerous  infiltration  is  not  dis- 
placed, as  it  may  become  during  the  growth  of  a  fibro-myomatous  tumour. 
The  ureter  may  be  greatly  displaced  by  the  benign  tumour,  yet  no  marked 
symptom  of  kidney  disease  be  produced.  In  the  course  of  the  cancerous 
infiltration  the  ureter  is  embedded,  not  puslied  aside ;  the  infiltration 
becomes  harder,  and  the  calibre  of  the  ureter  is  encroached  upon.  This 
constriction  of  the  ureter  leads  to  dilatation  of  the  tube  higher  up,  and 
results  in  hydronephrosis,  pyonephrosis,  atrophy,  or  some  other  of  those 
changes  which  go  on  in  a  kidney  the  ureter  of  Avhich  is  obstructed. 
The  symptoms  accompanying  these  serious  changes  may  be  comparatively 
slight ;  or  there  may  be  signs  of  marked  uraemia.  Sometimes  when  the 
patient  may  appear  to  be  in  danger  from  the  uraeTiiic  condition  alone, 
sudden  relief  may  be  obtained  by  rupture  of  the  ureter  into  the  ulcerat- 
ing cavity  of  the  uterus  and  the  establishment  of  a  fistula.  Such  a 
method  of  relief,  however,  is  not  an  incident  to  be  counted  upon,  but  it 
may  be  produced  by  operation,  and  has  occasionally  been  done.  If  symp- 
toms of  uraemia  once  come  on,  we  may,  with  confidence,  conclude  that 
the  prognosis  as  to  length  of  life  is  extremely  gloomy ;  and  it  becomes 
worse  the  harder  and  more  nodular  and  fixed  the  mass  around  the  uterus 
has  become.  This  is  a  point  of  the  very  greatest  importance  in  dealing 
with  advanced  cases  of  cancer  of  the  uterus,  and  specially  with  regard 
to  prognosis.  When  we  find,  on  examining  a  patient,  that  there  is  a 
hard  nodular  fixed  mass,  without  much  ulceration ;  when  we  learn  that 
there  are  irregular  haemorrhages,  comparatively  small  in  amount ;  and 
we  find  only  a  small  cavity,  or  no  cavity  at  all,  we  may  be  disposed  to 
count  on  producing  considerable  amelioration  by  treatment.  There  is 
usually  in  such  cases  a  considerable  amount  of  pain,  but  we  can  relieve 
pain;  and  inexperience  may  lead  us  to  take  a  hopeful  view  of  the  case 
seeing  that  there  is  no  considerable  danger  from  haemorrhage.  In  such 
cases,  if  we  overlook  the  signs  of  kidney  complications,  we  may  give  a 
favourable  prognosis  as  to  length  of  life,  and  yet  find  that  the  i)atient 
suddenly  dies,  or  rapidly  sinks  in  a  very  short  time  after  we  have  pro- 
nounced the  prospect  of  life  to  be  good. 

When  those  hard,  nodular,  non-ulcerating  masses  are  found  filling  the 
pelvis,  one  or  other  kidney  may  be  found  distinctly  enlarged,  giving 
perhaps  the  impression  of  being  cystic.  This  is  all  the  more  easily 
made  out,  because  of  the  emaciation  characteristic  of  this  advanced  stage 


MALIGNANT  DISEASES   OF  THE    UTERUS  667 

of  the  disease.  This  enlargement  should  be  always  looked  for  in  the 
first  examination  of  a  case. 

Dilatation  of  the  ureters,  till  they  look  like  loops  of  small  intestine, 
is  by  no  means  a  rare  condition,  as  shown  by  post-mortem  examination 
in  ureemic  cases,  and  in  cases  of  veiled  ursemia. 

Much  stress  is  purposely  laid  here  on  this  feature  of  the  late  stage  of 
cancer,  as  so  little  guidance  is  to  be  found  in  text-books,  and  the  con- 
dition of  the  urinary  organs  is  of  the  first  importance  in  regard  to 
prognosis.  Late  in  the  course  of  the  disease  we  may  find,  as  the  result 
of  the  ulceration,  fistula  between  the  bladder  and  the  ulcerating  utero- 
vaginal cavity ;  this  is  an  inevitable  result  of  the  cancerous  process  if 
the  patient  live  long  enough.  We  may  find  recto-vaginal,  or  recto- 
uterine fistula,  which  is  a  much  rarer  condition  of  parts  than  the  vesico- 
vaginal fistula ;  or  both  anterior  and  posterior  fistulas  may  be  established, 
producing  the  condition  of  cloaca.  By  this  time  the  patient  is  in  a  very 
miserable  state  owing  to  pain  and  the  impossibility  of  preventing  dis- 
charges, foul  smells,  and  irritation. 

Long  before  this  time  the  "  cancerous  cachexia  "  has  become  estab- 
lished. The  haemorrhage,  foul  and  profuse  discharge,  pelvic  pain,  irri- 
tability of  the  bladder,  loathing  of  food,  and  slight  sapraemic  and 
inflammatory  feverishness,  bring  about  a  change  in  the  patient's  appear- 
ance which  is  quite  characteristic.  It  is  marked  by  loss  of  flesh,  a 
peculiar  unwholesomeness  or  yellowish  pallor  of  the  whole  skin,  loss  of 
colour  of  the  lips  and  even  of  the  tongue,  occasional  puffiness  about  the 
eyelids,  habitual  want  of  animation,  or  even  an  expression  of  depression 
of  spirits,  and  an  indescribable  air  produced  by  want  of  rest  and  constant 
physical  suffering.  If  there  be  an  element  of  uraemia  in  the  case  there 
are  superadded  the  special  symptoms  which  it  produces  in  its  slighter 
and  slowly  developing  forms ;  chiefly  hebetude,  drowsiness,  and  impair- 
ment of  vision. 

The  final  stage  of  cancer  of  the  uterus  does  not  present  any  new  or 
important  symptom.  The  patient  is  past  the  stage  of  profuse  haemor- 
rhage. She  is  auffimic,  uraemic,  and  sapraemic,  emaciated,  and,  apart  from 
quality,  the  quantity  of  blood  in  the  body  has  become  comparatively 
small.  Owing  to  this  fact,  and  the  weakness  that  affects  the  heart  as 
well  as  every  other  organ,  occurrence  of  severe  htemorrhage  is  rare, 
although  exceptionally  it  may  be  the  immediate  cause  of  death  from 
ulceration  through  the  walls  of  a  considerable  artery. 

Owing  to  the  increase  of  the  cancerous  mass,  we  may  find  signs  of 
pressure  upon  the  blood-vessels  in  the  pelvis,  just  as  we  find  pressure 
upon  the  ureters.  There  may  be  some  oedema  of  one  or  both  limbs. 
There  may  also  be  pressure  on  the  sacral  nerves,  producing  distressing 
aches  or  cramps  in  one  or  other  of  the  lower  extremities.  Later  still  we 
may  occasionally  discover  thrombosis,  which  is  a  comparatively  rare  con- 
dition, because  few  of  the  patients  live  to  the  time  at  which  it  comes  on. 
If  we  find  persistent  local  areas  of  oedema,  local  areas  of  pain,  with 
change  of  colour  about  the  inside  of  the  thigh,  or  about  the  groin,  iudi- 


668  SYSTEJI   OF  GYN. -ECO LOGY 

eating  that  tlirombosis  or  phlebitis  has  occurred,  then  we  may  feel 
assured  that  the  patient  has  not  long  to  live. 

Xow  these  conditions,  symptoms,  and  local  changes,  occurring  in  the 
various  parts,  have  been  described  in  sequence;  but  they  develop,  of  course, 
more  or  less  simultaneously.  In  this  advanced  state  the  patient,  as  a  rule, 
is  constantly  in  pain ;  in  the  back,  in  the  groins  and  thighs,  and  in 
the  hypogastrium.  It  is  a  question  whether  there  is  any  nocturnal 
exacerbation  of  the  pain  in  the  advanced  stage  when  there  is  a  fixed  mass 
in  the  pelvis.  If  such  patients  do  not  receive  soothing  medicines  their 
pain  impresses  itself  more  upon  them  in  the  sleepless  and  silent  hours 
of  the  night,  but  there  is  no  proof  from  exact  clinical  observation  that 
severe  painful  exacerbations  occur  regularly  in  the  night  or  at  other 
definite  times  like  the  maximum  and  minimum  of  the  barometer. 

It  is  not  often  that  we  meet  with  cases  which  have  run  their  course 
without  medical  or  surgical  interference.  Such  cases,  however,  are  on 
record,  and  illustrate  the  natural  history  of  ulcerating  epithelioma 
originating  in  the  vaginal  portion.  The  symptoms  may  attract  so  little 
attention  throughout  that  medical  advice  may  not  be  sought  until  the  end. 

Causes  of  Death  from  Cancer  of  the  Uterus.  —  Supposing  we  have  to  do 
with  an  advanced  case,  we  must  consider  what  facts  would  lead  us  to 
anticipate  an  early  fatal  termination.  In  what  direction  will  the  compli- 
cations appear  which  will  lead  to  the  inevitable  end  ?  In  a  large  number 
of  cases  there  seems  to  be  no  special  dii'ection.  The  patient  dies  from 
marasmus,  from  want  of  nutrition  of  the  tissues,  and  consequent  loss  of 
power  of  the  whole  organisation  —  of  the  muscles,  heart,  organs  of  respira- 
tion, and  nervous  system.  We  may  call  it  merely  loss  of  strength,  or  by 
the  more  pedantic  name  of  asthenia.  Occasionally,  owing  to  some  com- 
plication, we  find  peritonitis  spreading  from  the  uterus  to  the  pelvis 
generally,  and  even  beyond  it ;  causing  pain  and  further  depression  of 
the  heart's  action.  It  may  also  be  accompanied  by  diarrhoea,  which 
precedes  the  fatal  termination.  Occasionally,  in  advanced  cases,  we  find 
that  the  disease  spreads  to  the  Fallopian  tubes,  causing  a  cancerous  form 
of  pyosalpinx ;  just  as  we  find  in  some  cases  that  obstruction  of  the  os 
internum  with  bacterial  infection  produces  the  cancerous  form  of  pyo- 
metra.  From  the  tubes  the  inflammatory  process  may  spread  to  the 
ovaries  and  peritoneum.  But  general  peritonitis,  from  some  sudden 
giving  way  of  protective  adhesions,  or  bursting  of  an  abscess  of  the  tube 
or  ovary  arising  from  cancer,  is  of  very  rare  occurrence. 

CEdema  of  the  lungs,  heart  failure,  ascites,  are  local  indications  of 
extreme  loss  of  strength.  But  the  commonest  of  all  the  complications 
arises  from  the  interference  with  the  functions  of  the  kidneys  by 
pressure  upon  the  ureters,  though  urannic  convulsions  are  eomjiaratively 
rare.  Occasionally,  but  very  seldom,  sudden  haemorrhage  is  the  imme- 
diate cause  of  death.  Sometimes  women  who  have  not  been  recently 
bleeding  to  any  alarming  extent,  but  who  are  greatly  reduced  by  all  the 
causes  that  have  been  already  enumerated,  suddenly  have  an  attack  of 
haemorrhage.     Tn  their  general  condition  they  cannot  stand  much  further 


MALIGNANT  DISEASES   OF   THE    UTERUS  669 

loss,  and  a  sudden  gush  of  liseniorrhage,  owing  to  ulceration  through  some 
vessel  even  of  .comparatively  small  size,  causes  syncope,  and  the  patient 
thus  suddenly  dies.  If  a  tampon  were  immediately  applied  the  haemor- 
rhage  might  be  stopped ;  but,  as  a  rule,  in  the  sort  of  case  under  con- 
sideration skilled  assistance  is  not  at  hand,  and  the  haemorrhage  is  the 
final  episode  in  the  story.  This  termination,  hoAvever,  may  be  consid- 
ered to  be  comparatively  rare.  Of  the  cases  that  I  have  had  under  my 
care,  I  can  remember  only  two  or  three  in  which  haemorrhage  was  the 
immediate  cause  of  death. 

Duration  of  the  Disease. — With  this  subject  of  the  causes  of  death 
comes  the  question  as  to  the  duration  of  life  in  any  given  case  of 
cancer.  This  is  a  question  which  we  are  always  asked  when  the 
diagnosis  has  been  finally  established ;  and  it  is  one  that,  with  the  evi- 
dence which  is  available,  we  can  seldom  answer  in  a  manner  satisfactory 
to  ourselves.  Extreme  periods  have  been  set  down  as  the  duration  of 
cancer ;  but  there  are  no  two  cases  alike,  and  any  application  of  averages 
becomes  misleading.  The  patients,  as  a  rule,  are  not  greatly  dissimilar 
in  certain  respects.  By  the  time  the  first  symptoms  of  cancer  show 
themselves,  the  vast  majority  of  them  are  in  comparatively  poor  health, 
and  if  they  belong  to  the  same  class  socially,  they  have  gone  through 
similar  experiences  of  life.  But  the  phenomena  of  the  disease  may 
widely  differ.  In  some  cases,  especially  in  the  comparatively  young, 
the  disease  spreads  rapidly  ;  in  some  cases,  especially  in  the  more  elderly, 
it  has  a  very  slow  development  indeed.  By  the  time  the  doctor  is  con- 
sulted the  disease  has  almost  invariably  made  considerable  progress,  and 
it  is  seldom  possible  to  learn  with  exactitude  when  the  disease  began. 
We  can,  therefore,  only  guess  from  the  symptoms  at  the  probable  dura- 
tion of  life  in  the  individual  case.  We  may  find  a  case  of  infected 
uterus  with  considerable  ulceration  in  the  cavity;  and  3'et  we  may 
confidently  say  the  patient  has  a  fair  prospect  of  living  two  or  three 
years.  The  tendenc}^  in  our  predictions  is  to  exaggerate  the  rate  of 
progress  which  the  disease  will  make,  and  therefore  to  make  statements 
minimising  the  patient's  prospect  of  life.  But  if  we  take  the  case  of  a 
patient  who  is  not  suffering  pain,  and  whose  uterus  is  not  fixed,  we  may 
say  that  the  condition  is  the  most  favourable  to  continuance  of  life.  And 
yet  we  are  all  very  liable  to  make  mistakes.  By  seeing  the  case  only 
two  or  three  times  at  intervals  one  can  hardly  forecast  its  future  progress. 
In  a  recent  post-climacteric  case,  at  the  time  of  the  first  consultation,  the 
doctor  in  attendance  had  not  made  an  examination  for  several  weeks 
previously ;  at  that  date  he  was  not  quite  certain  of  the  diagnosis, 
but  thought  there  was  a  suspicious  nodule  on  the  vaginal  portion  at  the 
OS ;  slight  ha3iporrhage  had  also  occurred,  and  had  recurred  a  few  days 
before  we  saw  the  patient  together.  On  our  visit,  on  the  posterior  lip 
including  the  os,  there  was  a  distinct,  small,  ulcerated  nodule.  The 
patient  was  sixty  years  old,  and  had  enjoyed  good  health.  Total  extir- 
pation of  the  uterus  without  delay  was  recommended,  but  the  ])atieut's 
objections  Avere  not  overcome  for  more   than  six  weeks.     Xo  further 


670  SYSTEM   OF  GYNECOLOGY 

examination  was  made  until  the  patient  was  on  the  operating  table, 
and  when  the  parts  were  exposed  an  amazing  development  was  found : 
the  small  nodule  had  become  a  great  ulcerating  mass ;  the  whole  of  the 
vaginal  portion  Avas  distinctly  involved,  and  owing  to  vaginitis  by  con- 
tact posteriorly,  it  was  necessary  to  begin  unusually  low  down  in  the 
vagina  in  order  to  remove  all  suspected  parts.  In  such  a  case  as  this, 
when  an  elderly  woman  with  a  comparatively  small  nodule  first  men- 
tioned the  slight  haemorrhage,  one  might  have  been  disposed  to  regard 
the  case  as  a  favourable  one,  and  to  estimate  the  prospect  of  life  at  two 
or  three  years  or  more. 

When  we  meet  with  a  patient  on  whose  face  the  cancerous  cachexia 
is  impressed,  whose  symptoms  date  back  for  many  months,  whose  uterus 
is  fixed  and  ulcerating,  and  about  whom  there  is  a  haunting  foetor,  hoAV- 
ever  slight,  we  can  only  look  for  a  short  and  downward  course.  We 
may  say  that  the  patient  will  live  a  year,  but  we  know  that  a  considera- 
ble portion  of  the  time  in  this  last  stage  will  be  really  passed  in  intol- 
erable suffering,  only  to  be  relieved  by  the  judicious  application  of  a 
process  of  euthanasia.  In  such  cases,  too,  we  must  always  look  for  em- 
barrassment of  the  kidneys,  and  keep  in  mind  that  there  may  be  a  rapid 
or  sudden  termination  in  ursemic  convulsions,  or  in  hebetude  deepening 
into  coma  which  may  be  their  equivalent. 

II.  Cancer  of  the  Cervix.  —  After  what  has  been  already  said,  the  con- 
sideration of  cancer  of  the  cervix,  in  the  narrower  sense,  need  not  detain 
us  long,  if  we  direct  our  attention  strictly  to  carcinoma  eervicis  uteri, 
and  not  to  those  forms  of  malignant  disease  which  are  often  described 
as  such,  but  which  are  certainly,  or  almost  certainly,  cancer  beginning 
in  the  circle  of  the  os  externum.  Such  cases  should,  strictly  speaking, 
be  regarded  as  forms  of  cancer  of  the  portio  vaginalis. 

Cancer  of  the  cervix,  in  the  restricted  sense  indicated,  occurs  in  two 
well-marked  forms.  In  the  first  of  these,  if  in  a  comparatively  early  and 
clearly  distinguishable  stage,  the  patient  mentions  symptoms  which  sug- 
gest malignant  disease.  There  is  the  characteristic  form  of  haemorrhage, 
and  there  is  a  tolerably  profuse  and  suspicious  discharge  which  may  or 
may  not  have  become  offensive.  Offensiveness  of  the  discharge  depends 
upon  bacterial  infection ;  and  the  cervix  is  protected  from  infection  in 
the  early  stage  of  the  disease  in  the  same  way  as  cancer  occurring  in  the 
cavity  of  the  body,  but  in  a  less  degree.  It  is  the  proliferation  of 
epithelium,  the  consequent  reaction  in  the  tissues  with  congestion  and 
profuse  discharge  from  the  cervical  glands,  and  finally  ulceration  which 
bring  about  the  characteristic  thin,  sanious,  or  dirty  water  discharge 
from  the  affected  area.  Most  pathologists,  and  clinicians  who  pay  special 
regard  to  pathology,  are  agreed  that  the  disease  originates  in  the  deeper 
cells  of  the  cervical  glands  ;  not  more  superficially.  Sir  John  Williams, 
for  example,  on  this  subject  says :  "The  starting-point  of  cancer  of  the 
cervix  is,  in  so  far  as  T  have  seen,  the  cervical  glands.  I  have  seen  no 
clear  instance  in  which  the  disease  originated  in  the  epithelium  of  the 


MALIGNANT  DISEASES    OF    THE    UTERUS  671 

surface."  This  conclusion  may  be  accepted  as  a  representative  statement 
of  the  opinions  of  the  most  competent  clinical  observers. 

As  the  disease  advances,  the  destruction  of  tissue  proceeds  upwards 
towards  the  os  internum,  and  in  this  class  of  case  it  sometimes  invades  and 
passes  beyond  tlie  internal  os.  At  an  equal  rate,  as  a  rule,  it  passes  down- 
wards, chiefly  destroying  the  mucous  lining,  and  invading  more  or  less 
the  parenchyma  of  the  cervix.  In  the  supposed  example  seen  before 
destruction  of  the  vaginal  portion  is  greatly  advanced,  the  cervix  will 
be  found  enlarged,  but  not  usually  to  a  very  marked  degree.  The 
os  externum  may  be  more  or  less  patulous,  probably  plugged  by  un- 
healthy looking  slime,  mixed  with  turbid  or  sauious  serum  ;  and  the 
first  impression  on  inspection  through  the  speculum  is  that  the  case 
is  one  of  marked  erosion.  There  is  a  ring  of  eroded  mucous  lining 
extending  more  or  less  widely  round  the  external  os.  But  in  the  cases 
of  which  we  can  speak  with  confidence,  there  is  something  both  in  the 
colour  of  this  eroded  area  and  in  the  appearance  of  the  discharge  that 
suggests  malignancy.  The  tissues  are  not  found  hard,  irregular,  or 
nodular  on  the  first  digital  examination.  It  is  the  patient's  appearance 
which,  taken  with  the  symptoms,  excites  suspicion.  If  in  such  a  case 
the  sound  be  used,  it  will  give  the  impression  of  touching  abnormally 
soft  and  probably  irregularly  distributed  tissues ;  and  if,  on  suspicion 
being  roused,  a  suitable  sharp  curette  be  passed  through  the  internal 
OS  and  tried  upon  the  cervical  tissue,  this  will  be  found  soft  and  flabby, 
and  there  will  be  no  difficulty  in  obtaining  shreds,  or  rather  plugs  for 
examination. 

In  some  cases  further  advanced,  where  the  ring  of  the  os  is  still 
more  or  less  intact,  the  curette  may  break  down  a  portion  of  the  tissues 
surrounding  the  os  uteri,  and  expose  a  cavity  filled  with  friable  necrosed 
cervical  material.  At  this  stage  there  is  still  no  invasion  of  parametric 
connective  tissue ;  and,  consequently,  the  case  is  in  the  most  favourable 
condition  for  total  extirpation. 

The  second  form  is  comparatively  rare,  but  there  are  points  in  it  of 
great  interest  from  the  surgeon's  point  of  view.  It  may  be  called  the 
scirrhous  form  of  cervical  cancer. 

An  ordinary  case,  as  met  with  in  practice  when  the  disease  has  suffi- 
ciently advanced  to  make  the  subject  of  it  seek  for  medical  relief, 
presents  on  vaginal  examination  a  hard,  irregular  vaginal  portion,  sug- 
gesting that  peculiar  cartilaginous  hardness  which  is  often  found  tow- 
ards the  menopause  in  a  woman  who  has  suffered  for  many  years  from 
chronic  cervical  catarrh.  Digital  examination  also  usually  reveals  the 
fact  that  the  iiterus  is  movable,  or  the  movements  are  only  slightly 
embarrassed.  The  first  step  in  physical  examination  probably  also  proves 
that  no  haemorrhage  is  produced  by  touch,  and  that  there  is  little  dis- 
charge. Fain  is  the  symptom  which  has  led  the  patient  to  seek  advice ; 
hence,  probably,  the  reason  why  such  cases  are  seen  in  a  comparatively 
early  stage  of  the  disease.  The  patient  has  usually  jiassed  the  meno- 
pause, and  for  years  has  been  free  from  symptoms  referable  to  the  pelvis. 


672  SYSTEM  OF  GYNAECOLOGY 

On  examination  with  the  speculum,  it  is  found,  that  the  external  os 
uteri  is  comparatively  little  involved.  There  is  probably  a  hard,  un- 
wholesome, and  shallow  excavation  at  some  point  occupying  a  portion 
of  the  circumference  of  the  part.  All  that  is  visible  of  the  rest  of 
the  uterus  may  ajDpear  comparatively  anaemic ;  there  are  usually,  in  fact, 
merely  indications  of  senile  changes.  Investigation  into  the  condition 
of  the  cervix  with  the  probe  or  sound,  produces  only  slight  heemorrhage. 
If  for  the  purpose  of  this  inspection  the  vaginal  portion  be  seized,  with  a 
volsella,  it  will  be  found  then  that  the  movement  of  the  uterus  downwards 
is  much  the  same  as  in  the  later  stage  of  convalescence  in  perimetritis. 
^Movement  is  only  slightly  diminished.  The  sound  may  be  passed 
through  the  cervical  canal,  which  Avill  be  found  narrow  and  irregidar. 
In  the  cases  in  which  I  have  succeeded  in  extirpating  the  uterus  the 
body  has  been  found  uninvaded  and  senile.  This  variety  of  malignant 
disease  of  the  uterus  is  the  only  one  which,  at  the  early  stage,  may 
suggest  an  exception  to  the  conclusiveness  of  the  evidence  produced  by 
the  sharp  curette.  It  requires  firm  pressure  with  the  instrument  to 
break  through  the  surface  of  the  hard  ulcer. 

On  further  examination  of  a  characteristic  case,  there  may  be  found 
some  indications  of  invasion  of  the  one  or  other  sacro-uterine  fold  ;  but 
in  spite  of  this,  the  gynaecologist  will  probably  be  strongly  tempted  to 
pronounce  the  case  suitable  for  extirpation  and  he  may  confide  to  his 
colleague,  the  general  practitioner,  that  the  operation  will  be  compara- 
tively easy.  If  he  proceeds  to  operation  he  will  find  the  directly 
opposite  to  be  true.  The  most  striking  characteristic  of  this  form  of 
malignancy  is  a  comparatively  early  invasion  of  the  connective  tissue, 
both  laterally  and  between  the  uterus  and  bladder.  There  may  even  be 
adhesions  of  the  intestine  in  Douglas'  space ;  and  in  the  course  of  opera- 
tion extreme  difficulty  is  consequently  experienced  in  reaching  the  peri- 
toneum either  in  front  or  behind.  If  the  surgeon  do  succeed  in  extirpating 
the  uterus,  it  need  hardly  be  said  that  he  may  anticipate  a  compara- 
tively early  recurrence. 

Wlien  the  parts  removed  are  examined  after  extirpation,  the  cervix 
presents  comparatively  little  hypertrophy,  with  generally  hard  tissues, 
and  occasionally  witli  harder  nodules  distributed  throughout.  In  no 
case  have  I  seen  any  indication  of  softening.  The  pain  probably  arises 
from  the  early  invasion  of  the  circumcervical  connective  tissue,  and  the 
liardening  of  the  cervical  parenchyma.  In  one  such  case  which  occurred 
several  years  ago,  the  operation  took  over  two  hours,  chiefly  owing  to  the 
firmness  of  the  ccillulai-  tissue  between  the  cervix  and  bladder,  and  on  the 
posterior  surface  of  the  uterus  between  the  vagina  and  the  peritoneum 
of  Douglas.  During  the  operation  the  bladder  wall  was  so  thinned  thait 
a  fistula  soon  afterwards  formed  and  gave  rise  to  great  distress. 

I  have  recently  seen  another  case  on  which  I  operated  two  years  and 
seven  months  ago.  Owing  to  difficulties  from  the  causes  indicated,  I  had 
to  rest  satisfied  with  amputation  at  the  internal  os,  and  the  use  of  pressure 
forceps  in  the  l(;ft  Ijroad  ligament,  which  presented  uuexpoctiid  difficulties. 


MALIGNANT  DISEASES   OF   THE    UTERUS  673 

It  seems  that  after  convalescence  the  patient  went  on  for  two  j'ears  with- 
out a  symptom,  and  then  she  was  attended  by  a  doctor  for  several  weeks, 
owing  to  an  attack  of  phlebitis  in  the  left  leg  after  unusual  exertion  during 
a  holiday  tour.  She  complained  of  nothing  further  until  quite  recently, 
when  she  again  called  in  the  doctor  on  account  of  some  discomfort  in  the 
groins  and  some  increase  in  the  amount  of  discharge.  Tliis  was  only  a  few 
days  before  my  visit.  When  we  saw  the  patient  together,  her  chief  com- 
plaint Avas  of  two  large  tender  masses  of  glandular  sAvelling  in  the  groins. 
She  complained  of  no  abdominal  pain,  and  she  said  but  for  the  painful 
swellings  she  would  have  been  "  knocking  about."  On  further  examina- 
tion there  was  found  a  mass  tilling  the  pelvis,  but  capable  of  compara- 
tively free,  elastic  movement.  There  was  no  ulceration  nor  appearance 
of  unequal  consistency  in  the  mass.  A  prominent  feature,  however,  was 
a  large,  comparatively  soft  nodule  on  the  vaginal  surface  of  the  urethra, 
with  a  considerable  area  of  infiltration  of  the  vaginal  wall  around  it. 
This  soft  nodule  is  almost  certainly  a  fresh  centre  of  development  of 
cancer,  with  a  proportion  and  arrangement  of  its  constituent  elements 
entirely  different  from  the  original  disease;  and  from  this  cancerous 
area  doubtless  comes  the  glandular  invasion. 

Diagnosis.  — The  diagnosis  of  cancer  of  the  uterus  must  be  established, 
as  in  most  cases  of  disease,  by  the  anamnesis,  and  by  physical  examina- 
tion. In  an  ordinary  case  of  cancer  of  the  portio  or  cervix,  in  which 
the  disease  is  so  far  advanced  as  to  rouse  the  patient's  anxiety  by  the 
persistence  of  certain  symptoms,  the  diagnosis  of  cancer  is  among 
the  easiest  of  case-problems  with  Avhich  the  practitioner  has  to  deal. 
There  is  the  history  of  irregular  A^aginal  hasmorrhage,  if  there  be 
nothing  else.  An  irregular  vaginal  liEemorrhage  should  always  lead 
to  physical  examination  without  delay.  On  making  a  vaginal  ex- 
amination in  such  a  case,  even  when  the  disease  is  not  sutficiently 
advanced  to  produce  fixation  of  the  uterus,  the  diagnosis  can  usually  be 
settled  by  palpation  alone.  There  is  either  a  hypertrophic,  hard,  irregular 
nodular  condition  of  the  vaginal  portion  of  the  uterus,  Avhich  is  friable  and 
readily  bleeds  under  the  exploring  finger,  or  there  is  more  or  less  of  an 
excavation  with  hard,  irregular  edges.  This  condition  may  affect  either 
lip  of  the  cervix  uteri ;  in  cases  of  old  and  deep  laceration  of  the  cervix 
it  invariably  at  first  affects  one  or  other  lip.  At  this  stage  the  disease 
seldom,  if  ever,  invades  the  cicatrix  at  the  apex  of  the  laceration.  In  the 
cases  in  Avhich  the  disease  is  further  advanced,  there  is  more  or  less  of 
hxation  of  the  uterus  with  excavation ;  seldom,  perhaps  never,  does  the 
uterus  become  fixed  whilst  the  disease  is  in  a  stage  of  mere  h}'pertrophy 
Avith  ulceration  of  the  vaginal  portion,  or  even  in  fairly  advanced  cases 
of  cauliflower  excrescence.  Palpation  of  caulifloAver  excrescence  settles 
the  question  of  malignancy  Avithout  any  further  question  of  physical 
exploration.  In  the  comparatively  early  stage,  should  palpation  not 
settle  the  question  in  the  mind  of  the  practitioner,  the  speculum  must  be 
brought  to  his  aid.  It  is  only  in  the  cases  of  flat  cancroid  or  early 
ulceration  that  any  additional  information  essential  for  diagnosis  can  be 

2x 


674  SYSTEM   OF  GYNECOLOGY 

gained  by  visual  inspection.  The  ability  to  distinguish  between  the 
worst  case  of  cervical  catarrh  produced  by  laceration  with  ectropium,  and 
complicated  Avith  ulcerating  cervical  glands,  and  the  earlier  stage  of  pos- 
sibly malignant  disease,  implies  a  familiarity  with  the  various  phases  of 
non-malignant  disease  of  the  vaginal  portion  of  the  uterus.  The  malignant 
condition,  however  early,  always  presents  an  appearance  of  "  unwhole- 
someness '"  which  is  never  seen  in  the  extremest  form  of  non-malignant 
change.  Speaking  of  a  case  in  this  early  stage,  Sir  John  Williams  says 
of  the  affected  portion,  ''  It  was  not  hard,  it  was  not  unduly  red,  it  bled 
slightly  on  digital  examination,  it  did  not  enlarge,  and  yet  it  looked 
vicious."  In  such  a  case  the  tissue  would  be  friable.  There  is  a  dis- 
coloration, especially  about  the  edges  of  the  area  of  invasion,  usually  a 
darker  shade,  which  can  no  more  be  described  than  can  a  smell,  but  which 
is  never  seen  in  non-malignant  lesions.  It  is  not  possible  to  lay  too  much 
stress  upon  the  need  for  diagnosis  at  this  early  stage  of  malignant  disease : 
the  life  of  the  patient  depends  upon  correctness  of  early  diagnosis.  It 
is  quite  true  that  temporising  is  permissible  to  some  extent ;  delay  may 
be  unavoidable  in  some  exceptional  cases.  In  a  dubious  case  it  may  be 
best  to  scarify  the  surface  and  the  edges,  in  order  to  open  retention 
cysts,  and  then  to  apply,  for  a  few  days  in  succession,  some  medicated 
preparation  of  glycerine  which  will  not  discolour,  inflame,  or  otherwise 
greatly  change  the  appearance  of  the  suspected  surface.  Pure  glycerine 
is  a  suitable  dressing  for  diagnostic  purposes.  After  much  manipulation 
or  scarification  glycerine  with  a  small  proportion  of  tannic  acid,  or  of 
carbolic  acid,  or  of  both  combined,  is  perhaps  a  better  agent  for  the  pur- 
pose. If,  after  a  few  days  of  such  an  application  the  trifling  super- 
ficial wounds  do  not  present  a  healthy  appearance,  the  case  may  be 
looked  upon  as  gravely  suspicious.  But  in  this  early  stage,  for  diagnostic 
purposes,  the  great  feature  of  malignant  disease,  as  compared  with  any 
other  possible  disease,  is  the  friability  of  the  affected  tissue.  This  fact 
impressed  me  many  years  ago,  and  for  a  long  time  I  have  depended 
largely  upon  it,  as  I  consider  it  to  be  a  pathognomonic  indication  of 
the  presence  or  the  absence  of  malignant  disease  in  the  earliest  possi- 
ble stage.  The  method  of  diagnosis  resulting  from  this  great  fact  of 
friability  is  one  which  every  general  practitioner  may  apply  in  order 
to  establish  a  prima  facie  case.  This  friability  is  indicated  by  the  readi- 
ness with  which  the  volsella  tears  through  when  there  is  considerable 
infiltration  of  the  malignant  elements  ;  and,  in  the  less  advanced  cases, 
by  the  facility  with  which  one  can  fill  the  sharp  spoon  by  a  clearly  cut 
out  portion  of  tissue. 

If  a  mortal  disease  which  is  local  in  its  earliest  stages  is  permitted 
to  become  generalised,  there  must  be  something  very  defective  in  our 
knowledge,  convictions,  and  practice.  There  is  at  the  present  time  a 
tolerable  consensus  of  opinion  that  cancer,  affecting  the  cervix  uteri, 
can,  in  its  early  stages,  be  successfully  dealt  with  as  a  local  disease. 
All  specialists  in  gynascology,  who  have  turned  their  attention  to 
the  operative  treatment  of  cancer  of  the  \iterus,  lament  the  smallness 


MALIGNANT  DISEASES    OF   THE    UTERUS  675 

of  the  number  of  cases  that  come  into  their  hands  at  a  sufficiently 
early  stage  to  give  them  a  reasonable  hope  that  the  operation  of  extir- 
pation will  be  followed  by  a  full  measure  of  success.  Of  such  com- 
mon occurrence  is  cancer  of  the  uterus  that  cases  are  continually 
coming  into  the  hands  of  all  general  practitioners ;  and  it  is  on  their 
promptness  in  recognising  the  nature  of  the  disease,  and  in  dealing  with 
it  in  the  most  efficient  manner  at  present  known  to  us,  that  our  hopes 
of  any  considerable  improvement  in  practice  must  rest.  Most  of  the 
difficulties  in  the  way  of  obtaining  more  satisfactory  results  in  the 
surgical  treatment  of  uterine  cancer  arise  from  the  circumstances  under 
which  the  disease  occurs,  and  its  early  symptoms. 

For  the  prompt  and  efficient  treatment  of  the  cases  which  come  under 
our  observation  in  the  early  and  favourable  stage,  we  must  largely  depend 
upon  a  definite  and  easily  applicable  method  of  diagnosis.  Cancer  of 
the  cervix  uteri  in  the  ulcerative  stage  has  such  marked  characters,  and 
is  consequently  diagnosed  so  easily,  that  delay  in  applying  to  it  the 
radical  surgical  treatment,  if  it  has  not  already  passed  beyond  the  point 
at  which  such  treatment  can  be  of  service,  is,  with  our  present  available 
knowledge,  altogether  unjustifiable.  There  is,  however,  a  still  earlier 
stage  of  the  disease  Avhich  occasionally  comes  under  the  observation 
of  the  practitioner,  the  most  hopeful  stage  from  the  point  of  view  of 
surgical  interference,  which  is  too  often  allowed  to  pass  because  of  doubt 
as  to  the  significance  of  the  facts  observed  and  consequent  feebleness  in 
action.  Any  method  of  diagnosis  depending  upon  features  Avhich  are  to 
be  looked  for  in  any  given  case,  and  when  observed,  accepted  as  sufficient 
to  justify  action,  must  be  generally  available,  and  easy  of  application  by 
the  general  practitioner.  In  order  to  attain  the  maximum  amount  of  use- 
fulness, such  diagnostic  signs  must  be  found  with  comparative  ease  when 
looked  for,  and  their  verification  inust  not  require  any  processes  which 
demand  a  large  amount  of  time  and  care  and  special  knowledge.  The 
chief  objection,  as  a  method  of  diagnosis,  to  microscopic  examination  of 
tissue  obtained  from  a  portion  of  the  organ  suspected  is  the  difficulty  of 
its  application.  It  requires  special  knowledge  of  the  methods  of  obtaining 
and  preparing  tissues  for  microscopic  investigation  ;  and  even  wlien  the 
practitioner  possesses  the  needful  knowledge,  the  amount  of  time  required 
for  the  application  of  the  method  greatly  diminishes  its  value.  In  addition 
to  that,  we  have  to  remember  that  the  mere  histological  examination  of 
tissues  can  only  be  looked  upon  as  an  auxiliary  and  complement  to  the 
observation  of  clinical  facts,  not  as  a  substitute  for  it.  It  may  be  said  with 
confidence,  therefore,  that  the  usual  advice  given  in  books  and  clinical 
lectures,  under  the  head  of  diagnosis  of  cancer  of  the  cervix  uteri,  to  make 
a  histological  examination  of  the  suspected  tissues,  is  assigning  too  impor- 
tantapositiontoaproceedingof  more  apparentthan  real  usefulness.  What 
we  require  is  an  easily  applied  clinical  method  of  diagnosis,  such  as  will 
distinguish  early  cancer  from  any  other  condition  which  a  practitioner  of 
average  knowledge  and  intelligence  could  possibly  mistake  for  it,  —  a 
method  which  gives  at  the  same  time  a  moral  certainty,  or  at  least  the 


676  SYSTEM   OF  GYNAECOLOGY 

\&vj  strongest  presumption  that  the  diagnosis  depending  upon  it  is  cor- 
rect. Such  a  method  of  distinguishing  between  early  cancer  and  other 
conditions  which  more  or  less  resemble  it,  is  that  of  applying  the  test 
of  friability  of  tissue  which  is  characteristic  of  malignant  disease. 

If  in  any  given  case  under  examination  the  results  obtained  by 
palpation  and  the  closest  visual  inspection  still  leave  some  doubt  in 
the  mind  of  the  practitioner  whether  the  condition  be  early  cancer  of 
the  cervix,  the  doubt  will,  in  my  opinion,  be  invariably  cleared  up  by 
ascertaining  the  amount  of  friability  of  the  tissues.  The  suspected 
vaginal  portion  must  be  thoroughly  exposed  by  a  suitable  speculum,  and 
the  uterus  held  steady  by  the  volsella.  Then  with  the  sharp  curette  or 
spoon  an  attempt  is  made  to  scoop  out  some  tissue  from  the  suspected 
area.  If  the  disease  be  malignant  a  definite  compact  piece  of  tissue, 
larger  or  smaller  according  to  the  extent  of  the  infiltration  and  conse- 
quent friableness  of  the  tissue  thus  operated  upon,  will  be  obtained.  If 
the  disease  be  not  malignant,  a  firm  rub  with  the  sharp  curette  will 
only  make  the  part  bleed,  and,  at  the  most,  some  small  thin  threads  or  a 
pellicle  of  semi-translucent  epithelium  or  of  granulations  will  be  detached. 
The  difference  is  very  strikingly  brought  out  by  comparing  the  effects 
thus  produced  upon  a  case  of  old  chronic  cervical  catarrh,  marked  by 
hypertrophy,  ectropium,  and  retention  cysts,  with  the  effects  produced  by 
similar  forcible  application  of  the  spoon  to  the  tissues  in  the  early  stage 
of  epithelioma.  The  existence  of  this  contrast,  with  its  easy  application 
to  diagnosis,  is  of  the  greatest  importance  in  general  practice ;  inasmuch 
as  chronic  cervical  catarrh,  complicated  with  the  other  tissue  changes  just 
mentioned,  is  very  common,  and  is  almost  the  only  condition  at  all 
likely  to  be  mistaken  for  early  epithelioma  of  the  cervix.  If  we 
take,  for  example,  two  ordinary  cases,  one  of  malignant  disease,  the  other 
of  erosion  with  retention  cysts,  the  characteristic  difference  does  not 
appear  on  simple  inspection.  ,  In  the  case  of  malignant  disease  the  ring  of 
the  external  os  may  be  complete,  and  the  differential  diagnosis  by  simple 
inspection  would  have  to  depend  upon  a  mere  shade,  an  indescribable 
difference  in  the  colour  of  the  mucous  lining,  and  on  some  differences  in  the 
colour  and  degree  of  thinness  of  the  discharge  at  the  os  in  the  respective 
cases.  A  comparison  between  the  results  to  be  obtained  by  palpation 
does  not  bring  us  much  further  towards  the  coiu})letion  of  a  differential 
diagnosis.  In  both  cases  there  may  be  a  certain  amount  of  hardness, 
unevenness,  and  irregularity  in  the  consistency  of  the  tissues  about  the 
external  os ;  in  both  there  appears  to  be  some  hypertrophy  of  the  cervix; 
but  there  is  nothing,  so  far  as  touch  is  concerned,  that  would  justify  us  in 
saying  that  the  one  case  is  malignant  and  the  other  is  not,  and  in  acting 
accor(lingly.  Now  from  certain  facts  in  the  clinical  history  of  the 
malignant  case,  not  in  themselves  conclusive,  the  nature  of  the  disease 
is  suspected,  and  the  test  of  the  sharp  curette  is  applied.  The  instru- 
ment cuts  through,  from  inside  the  os  downward  to  the  vaginal  surface 
of  the  portio,  as  if  through  a  radish;  and  although  a  microscopic 
examination  of  the  tissues  may  still  be  made,  the  diagnosis  may  be 


MALIGNANT  DISEASES   OF   THE    UTERUS  d-j-j 

considered  complete  on  observing  the  effects  of  the  curette,  taken  in 
conjunction  with  the  other  clinical  facts,  quite  independently  of  the 
histology.  I  have  found,  on  extirpation  of  the  uterus  in  such  a  case, 
a  condition  of  considerable  ulceration  with  extensive  softening  and 
breaking  down  of  the  tissues  within  the  cervix  uteri,  extending  even 
above  the  internal  os. 

Quite  recently  I  had  the  opportunity  of  dealing  with  a  case  which 
formed  a  striking  illustration  of  the  application  of  this  method  of 
diagnosis  ;  the  clinical  history,  including  haemorrhage,  the  appearances, 
and  the  impression  obtained  by  palpation  supported  the  diagnosis, 
already  confidently  arrived  at  by  a  colleague,  that  the  patient  was 
suffering  from  epithelioma  of  the  cervix  uteri.  On  the  posterior  lip  of 
the  deeply  lacerated  cervix  was  a  considerable  area  apparently  devoid  of 
epithelium,  and  with  an  irregular  indurated  margin  studded  Avith  small 
retention  cysts,  some  of  which  were  ulcerating.  The  test  of  the  sharp 
curette  was  applied  with  a  negative  result,  —  that  is  to  say,  the  suspected 
surface  was  merely  made  to  bleed,  and  some  thin  particles  of  epithelium 
only  were  scraped  away.  A  distinct  mass  of  friable  uterine  tissue  was 
not  obtained ;  nevertheless  the  appearance  of  the  hypertrophied  eroded 
posterior  lip  was  so  suspicious  that  it  seemed  as  if  an  exception  to  the 
rule  had  been  found,  and  that  the  test,  as  a  universal  test,  had  failed. 
The  patient  was  kept  in  bed  for  several  days,  and  medicated  tampons 
were  applied  in  order  to  cleanse  thoroughly,  and  as  far  as  possible 
modify  the  appearance  of  the  suspected  area  in  a  healthy  direction. 
The  change  Avhich  took  place  was  of  small  avail  for  completing  the 
diagnosis,  and  the  sharp  curette  test  was  again  applied  with  the  same 
result.  It  was,  therefore,  decided  to  proceed  with  Emmet's  operation, 
as  the  most  effective  method  of  dealing  with  the  laceration  and  hyper- 
trophy ;  inasmuch  as  the  definite  conclusion  was  reached  that  the 
erosion  and  other  changes  could  not  be  owing  to  malignant  disease. 
In  performing  the  operation  the  incision  on  one  side  invaded  the 
margin  of  the  ulcer,  and  this  was  followed  immediately  by  a  gush  of 
the  fluid  characteristic  of  a  retention  cyst  of  the  cervix,  and  the  hard 
and  apparently  hypertrophied  posterior  lip  at  once  became  flaccid  and 
greatly  diminished  in  bulk.  This  retention  cyst  of  the  cervix  was  the 
largest  that  I  have  ever  seen.  The  operation  was  completed,  the  patient 
made  a  perfect  recovery,  and  I  heard  some  weeks  afterwards  from  her 
medical  attendant  that  the  symptoms  which  originally  caused  alarm 
had  subsided,  that  the  uterus  appeared  perfectly  healthy,  and  that  it 
was  almost  impossible  to  make  out  the  points  of  union  in  the  ring  of 
the  perfectly  restored  external  os. 

It  would  be  out  of  place  to  illustrate  the  method  or  to  elaborate 
the  description  further.  I  have  applied  it  myself  for  about  ten  years, 
and  have  never  found  it  to  fail.  The  suitable  application  of  it  pre- 
supposes a  reasonable  amount  of  knowledge  of  the  diseases  of  the  female 
sexual  organs,  and  the  due  consideration  and  appreciation  of  all  the 
relevant  clinical  facts  in  any  given  case  ;  when  anj-  doubt  still  remains 


678  SYS  TEA/   OF  GYNECOLOGY 

in  the  mind  of  the  practitioner,  the  effects  produced  by  the  sharp  curette 
or  spoon  shoukl  finally  settle  the  diagnosis  as  to  malignancy. 

When  the  operation  of  vaginal  hysterectomy  for  cancer  was  being 
introduced  into  this  country,  one  of  the  objections  raised  by  some  of 
the  senior  g^-naecologists  to  such  a  serious  operation  was  the  extreme 
difficulty  of  diagnosing  cancer  of  the  cervix  sufficiently  early.  But 
there  never  was  any  such  extreme  difficulty  in  diagnosis  as  used  to  be 
alleged ;  and  more  exact  observation  of  the  injuries  done  to  the  cervix 
in  parturition,  and  of  the  subsequent  and  resulting  changes  in  the  in- 
jured parts  which  may  take  years  to  establish,  has  done  much  to  mini- 
mise or  remove  any  reasonable  ground  for  doubt  if  it  ever  existed.  It 
is  only  in  such  cases  of  injury  that  doubt  as  to  the  benign  or  malignant 
nature  of  the  changes  is  excusable.  All  the  other  appearances  usually 
enumerated  as  simulating  cancer  have  only  a  superficial  resemblance  to 
it ;  ignorance  and  carelessness  are  essential  to  mistaken  diagnosis. 

The  iTse  of  the  curette  in  the  differential  diagnosis  of  malignant 
disease  of  the  body  of  the  uterus  is  better  known,  but  it  is  perhaps  not 
adopted  so  generally  as  it  ought  to  be.  Friability  is  characteristic  of 
the  malignant  growth  here  as  well ;  but  other  friable  structures  may  be 
found  fixed  in  the  body  which  are  only  found  detached  in  the  course  of 
expulsion  in  the  cervical  canal. 

English  gynascologists  who  have  given  special  attention  to  cancer  do 
not,  as  a  rule,  err  in  depreciating  the  value  in  exact  diagnosis  of  clinical 
work  as  compared  with  microscopic  examination;  but  there  may  some- 
times be  room  for  improvement  in  clearness  of  statement  of  the  value  of 
each  method  of  diagnosis  and  of  their  mutual  relationships. 

Specialists  in  diseases  of  women  and  pathologists  usually  assure  the 
general  practitioner  that  the  diagnosis  of  cancer  in  its  earlier  stages  is 
not  complete  without  microscopic  examination.  Such  an  assertion  dis- 
courages exact  clinical  observation,  and  is  equivalent  to  telling  the  gen- 
eral practitioner,  with  comparatively  few  exceptions,  that  he  is  incapable 
on  account  of  ignorance,  or  disabled  by  the  exigencies  of  his  professional 
life,  from  forming  a  sufficient  diagnosis  in  a  class  of  cases  of  frequent 
occurrence,  and  in  which  such  serious  practical  consequences  may  follow 
his  mistakes.  It  is,  moreover,  misleading  in  that  it  attaches  undue 
weight  to  a  method  of  diagnosis  which  experience  proves  to  be  unde- 
serving of  such  implicit  confidence. 

Sir  John  AVilliams,  in  his  work  on  Cancer  of  the  Uterus,  says  quite 
truly  that  clinical  observation  is,  as  a  rule,  not  equal  to  making  the 
distinction  between  the  different  kinds  of  malignant  diseases.  But  he 
understates  the  case  for  clinical  observation,  when  he  says  that "  weeks 
or  months  of  watching"  may  be  necessary  to  decide  whether  a  growth 
be  malignant  or  not;  and  he  overstates  it  on  the  other  side  when  he 
says :  "  During  the  early  stages  of  cancer  or  of  other  malignant  growths, 
the  microscope,  I  believe,  will  enable  us  to  recognise  and  make  sure  of 
the  disease  long  before  clinical  observation." 

Mr.  Knowsley  Thornton,  speaking  in  favour  of  clinical  observation, 


MALIGNANT  DISEASES   OF   THE    UTERUS  679 

called  attention  to  an  objection  to  microscopic  examination  Avhich  is  too 
often  overlooked.  He  said :  "  To  snip  out  a  bit  of  a  malignant  growth 
is  in  truth  to  perform  a  partial  operation,  and  thus  to  run  the  risk  of 
rapid  spread  to  distant  parts  through  the  opened  veins  and  lyinphatics. 
Clinical  observation,  if  sufficiently  close  and  painstaking,  will  generally 
give  a  distinct  diagnosis  in  good  time  for  successful  interference." 

On  the  other  hand,  Dr.  AV.  S.  A.  Griffith  goes  the  length  of  assert- 
ing: "In  all  doubtful  cases  of  disease  of  the  cervix  a  piece  of. the 
suspected  part  should  be  cut  out,  taking  care  to  include  the  margin  of 
the  healthy  and  affected  part,  and  be  carefully  preserved  and  submitted 
to  microscopical  examination."  Thus  implying,  we  may  assume,  that 
the  question  will  be  settled ;  they  will  be  no  longer  "  doubtful  cases." 

Dr.  Herman,  speaking  on  the  same  subject,  says :  "  I  think  the 
value  of  the  microscope  in  the  clinical  diagnosis  of  cancer  has  been  over- 
estimated. ...  A  diagnosis  based  on  the  microscopical  examination 
of  sections  of  tissues  must  be  accepted  with  great  reserve." 

It  may  be  stated  broadly  that  every  German,  and  almost  every 
Continental  gyneecologist,  supports  the  opinion  of  the  importance  of 
microscopic  examination  in  diagnosis.  Winckel  sa3^s  that  "  it  is  evident 
from  the  pathology  of  carcinoma  that  in  its  earlier  stages  the  disease 
can  be  recognised  onl}^  by  the  aid  of  the  microscope.  This  will  reveal 
the  characteristic  atypical  epithelial  proliferation  in  the  tissues,  and  the 
consequent  destruction  of  the  latter." 

Auvard,  who  is  almost  an  exception,  devotes  much  space  to  the  clinical 
features  in  establishing  the  diagnosis  ;  and  he  quotes  Cornil  to  show  that 
even  with  the  microscope  differential  diagnosis  may  be  impossible.  "An 
excised  portion  of  the  tumour  most  frequently  permits  an  experienced 
eye  to  arrive  at  an  anatomo-pathological  diagnosis ;  that  nevertheless  there 
are  cases  of  malignant  adenoma  (epitheliom)  in  which  it  is  difficult  to 
make  out  any  distinction  from  the  structure  of  simple  adenoma." 

Gusserow  (14),  in  speaking  of  the  early  stage  of  epithelioma  and  the 
difficulty  of  differentiating  from  erosion,  admits  that  erosion  has  been 
considered  by  some  observers  as  the  initial  stage  of  epithelioma,  while 
lv\ige  and  J.  Veit  maintained  at  first  that  they  were  the  beginnings  of 
true  carcinoma.  Gusserow,  believing  that  results  beyond  suspicion  could 
not  be  obtained  from  small  particles  of  the  diseased  tissue,  in  suspicious 
cases  practised  amputation  of  the  entire  vaginal  portion  in  order  to 
obtain  suitable  sections  for  microscopic  diagnosis,  even  at  the  risk  of 
now  and  again  operating  unnecessarily. 

Carl  Euge  (41)  says :  "  At  the  present  time  it  must  be  the  task  of 
the  physician  to  recognise  cancer  as  such  in  its  early  stage,  and  this  is 
possible  in  very  many  cases  onhj  hj  means  of  the  microscope." 

Such  opinions  are  held  by  men  who  know  that  hj-perplasia  of  the 
viterine  mucosa  has  been  mistaken  for  sarcoma,  and  that  many  original 
papers  have  been  written  quite  independently  in  support  of  the  discovery ; 
that  the  decidua  of  a  post-abortum  uterus  has  been  diagnosed  as  sarcoma ; 
that  degeneration  of  the  placenta  has  been  found  to  be  like  a  gumma  of 


68o  SYSTEM  OF  GYX.-ECOLOGY 

the  liver;  —  mistakes  all  made  by  pathologists  who  were  specialists  in 
gyngecology.  If  this  is  to  be  the  ultimate  position  of  microscopic 
diagnosis  in  gyncecology,  then  the  diagnosis  of  early  cancer,  on  which 
so  much  of  success  in  treatment  depends,  must  in  this  country  remain 
entirely  in  the  hands  of  some  junior  members  of  the  teaching  staffs 
of  metropolitan  hospitals  and  pro\dncial  medical  schools  during  the 
otiose  portion  of  their  professional  lives.  And  how  many  of  them  have 
had  the  necessary  experience  in  observing  the  peculiar  character  stamped 
upon  malignant  disease  as  it  occurs  in  the  uterus  ?  Every  man  who,  at 
some  period  of  his  comparatively  youthful  career,  acquired  some  dis- 
tinction in  the  study  of  Greek,  must  remember  the  ineffable  contempt 
with  which  in  those  days  he  listened  to  elderly  men  speaking  of  the 
extent  to  which  they  had  forgotten  their  classics  ;  and  the  same  man  at 
five-and-forty  must  in  his  turn  look  back  with  humility  or  amusement 
upon  their  early  notions  when  they  lind  themselves  unable  to  read  Avith 
ease  a  verse  of  the  Greek  Testament.  As  with  youth  and  the  "  ton- 
sured head  in  middle  age  forlorn,"  so  it  is  with  the  aforesaid  junior 
teaching  members,  and  even  the  best  educated  and  most  experienced 
and  thoughtful  of  elderly  general  practitioners.  I  have  no  hesitation 
in  saying  that  diagnosis  by  microscopic  examination,  as  far  as  the 
general  practitioner  is  concerned  into  whose  hands  come  the  over- 
whelming majority  of  cases  of  early  cancer  of  the  uterus,  is  simply 
impossible.  If  you  take,  for  example,  the  description  by  Kuge  and 
Veit  of  the  appearances  of  non-malignant  papillary  or  glandular  erosion 
of  the  cervix  uteri,  and  their  opinions  with  regard  to  the  appear- 
ances of  non-malignant  compared  witli  malignant  changes  within  the 
same  area,  their  statements  add  to  our  difficulties.  They  say  that  there 
is  no  clear  border  line,  so  far  as  histology  is  concerned,  between  the 
benign  and  malignant  changes  ;  and  it  requires  a  long  and  concentrated 
experience,  and  the  special  knowledge  and  acquirements  of  a  professional 
pathologist  who  has  given  much  attention  to  gynaecology,  to  make  out  the 
difference  with  such  clearness  and  confidence  as  to  guide  him  to  a  con- 
clusion on  a  question  implying  such  serious  practical  consequences  as 
whether  a  tissue  change  in  the  uterus  be  benign  or  malignant.  Though 
strongly  impressed,  through  the  experience  of  many  years,  with  the 
importance  of  clinical  observation  as  compared  with  the  microscopic 
examination  of  tissues  in  the  diagnosis  of  cancer  of  the  uterus,  as  well  as 
in  many  other  diseases  of  women,  I  have  been  afraid  of  the  responsibility 
of  formally  expressing  opinions  in  a  public  and  permanent  form,  wliich 
might,  liowever  unconsciously,  be  the  mere  indication  of  a  prejudice, 
rather  than  of  a  definite  induction  stated  with  a  practical  object.  I  Avill 
confess,  also,  to  a  shrinking  from  the  accusation  of  want  of  scientific 
knowledge.  All  of  us  do  not  yet  see  the  greater  and  the  less  in  some 
of  these  matters  in  their  just  proportions ;  and  it  is  as  fatal  at  the 
present  day  to  the  professional  character  of  a  man  to  be  accused  of 
being  merely  a  clinician  (a  thing  which  it  is  assumed  that  any  man  may 
be)  as  compared  with  being  a  scientific  histologist,  for  which  compara- 


MALIGNANT  DISEASES   OF   THE    UTERUS  68 1 

lively  few  men  have  the  opportunities  or  the  peculiar  gift,  as  it  is 
for  the  moral  character  of  a  man  to  take  up  a  strong  position  on  cer- 
tain social  questions.  The  motive  of  one  is  assumed  to  be  ignorance  of 
pathology  ;  of  the  other  to  be  sympathy  with  immorality.  Kuminating 
on  this  curious  fact,  and  impressed  with  the  importance  of  calling  atten- 
tion strongly  to  the  need  for  exact  clinical  observation  of  uterine  cancer, 
I  came  to  the  conclusion  that  any  expression  of  opinion  from  me,  even 
adequate  to  tlie  strength  of  my  convictions,  would  be  of  no  avail  under 
present  misconceptions  as  to  relative  values  in  professional  investigation 
and  practice;  and  I  thought  it  prudent  to  appeal  to  my  friend  and 
colleague,  Professor  Delepine,  to  describe  concisely  the  shortest  possible 
methods  by  which  the  general  practitioner  could  obtain  histological 
evidence  sufficient  to  justify  him  in  coming  to  a  definite  decision  as  to 
'  the  malignancy  or  non-malignancy  of  a  disease  of  the  cervix  uteri  by 
means  of  the  examination  of  a  portion  of  tissue  excised  or  curetted  from 
the  suspected  area.  His  account  of  a  rapid  method  of  examination 
may  be  of  use  to  others  besides  the  brethren  who  are  engaged  in  general 
practice. 

Description  of  the  simplest  methods  zvhich  ivill  give  trustworthy  results  in  the 
micro  SCO})  iced  examination  oftissiies  of  the  cervix  uteri  for  diagnostic 
purposes  (Professor  S.  Delepine). 

"  There  are  two  rapid  methods  which  can  be  used  with  success.  The 
first  consists  in  freezing  the  tissues  immediately  after  removal,  or  within 
a  few  hours.  The  other,  a  little  slower,  takes  about  twenty -four  or 
forty-eight  hours,  but  is  much  easier  to  carry  through. 

"  The  freezing  method  consists  in  taking  a  small  piece  of  tissue,  the 
most  resisting  and  fibrous  looking  parts  being  selected  Avhen  choice  is 
possible.  This  piece  is  dipped  into  some  mucilage  of  gum  arable,  and 
placed  at  once  on  the  plate  of  a  freezing  microtome.  It  is  partly  frozen 
through.  The  upper  incompletely  frozen  parts  are  removed,  and  then 
a  few  sections  are  cut  from  those  parts  which  have  not  yet  become  too 
hard.  These  sections  are  transferred,  one  by  one,  by  means  of  a  soft 
brush,  into  a  dish  containing  Midler's  fluid,  or  a  2  per  cent  solution 
of  bichromate  of  potash.  The  sections  are  left  in  this  solution  for  a 
few  minutes,  or  even  for  an  hour  or  two ;  and  then  they  are  spread  care- 

■  fully  on  a  slide.  They  may  be  stained  on  the  slide  with  lithium  i)icro- 
carmin,  and  mounted  in  Tarrant's  solution ;  or  they  may  be  stained  with 

.  haematoxylin,  or  htematein,  and  double  stained  with  eosin  (weak  solutions 
in  spirit  diluted  with  4  parts  of  water),  or  rubin  and  orange.  They 
can  then  be  mounted  in  Canada  balsam  after  the  usual  treatment ; 
namely,  dehydration  by  absolute  alcohol  and  clearing  in  oil  of  cloves,  both 
carried  out  as  rapidly  as  possible.  In  either  case  it  is  well  to  Avash  off 
the  Ml'iller's  fluid  rapidly  before  using  the  stains.  This  method,  which 
has  been  employed  in  my  laboratories  for  over  ten  years,  gives  good  re- 
sults Avhen  the  tissues  are  suitable ;  but  it  requires  a  certain  amount  of 


682  SYSTEM  OF  GYNAECOLOGY 

practice,  as  the  sections  Avhen  cut  fresh  have  a  great  tendency  to  curl 
or  stick  together,  and  also  to  shrink  during  the  process  of  mounting. 

''  The  other  method,  which  requires  a  little  longer  time,  consists  in 
placing  small  pieces  of  the  tissues  to  be  examined  in  ordinary  methy- 
lated spirit.  The  pieces  should  not  be  larger  than  a  small  bean,  and  the 
quantity  of  spirit  should  be  at  least  twenty  or  thirty  times  the  bulk  of 
the  tissues  to  be  hardened.  At  the  end  of  twelve  to  twenty -four  hours  it 
is  already  possible  to  obtain  tolerably  good  sections  from  such  pieces  ;  but 
it  is  better,  when  time  allows,  to  transfer  them  at  the  end  of  that  time 
to  absolute  alcohol,  and  to  leave  them  in  it  for  a  few  hours.  On  taking 
the  specimens  out  of  the  alcohol  they  are  placed  in  running  water  for 
one  or  two  hours ;  thence  they  are  transferred  to  mucilage  of  gum 
arabic  in  which  they  are  left  for  about  an  hour,  or  for  three  or  four 
hours  if  they  are  rather  soft.  Then  sections  are  cut  by  means  of  a 
freezing  microtome,  the  sections  being  received  in  Avater  and  stained 
afterwards  on  a  slide,  either  with  picrocarmin  or  rubin  and  orange. 

"  These  methods  do  not  give  results  which  can  be  compared  with  those 
obtained  by  more  complete  methods  of  fixing  and  hardening  by  per- 
chloride  of  mercury  or  chromic  acid,  and  passage  through  alcohol  of 
increasing  strength,  but  they  are  quite  sufficient  for  diagnostic  purposes. 
I  have  lately  tried  quick  hardening  by  means  of  the  formaldehyde 
method,  and  found  this  method  satisfactory  ;  but  it  does  not  present  any 
considerable  advantages  over  the  slightly  longer  alcoholic  method." 

We  need  have  no  hesitation  in  saying  that  busy  men,  almost  without 
exception,  will  declare  that  if  such  proceedings  are  essential  to  the  early 
diagnosis  of  cancer,  then  most  of  the  cases  that  come  into  their  hands 
must  remain  undiagnosed  until  more  obvious  malignant  characters  have 
been  developed.  The  history  of  the  case,  often  so  difficult  to  obtain  with 
preciseness  and  cleared  of  irrelevances,  and  the  knowledge  acquired  by 
exact  jjhysical  examination,  that  is  to  say,  the  clinical  facts,  keeping 
always  in  mind  the  great  feature  of  friability  of  tissue,  are  sufficient 
to  establish  a  prima  facie  conclusion  as  to  the  nature  of  the  case  to 
be  dealt  with.  When  the  clinical  test  establishes  at  least  a  very  strong 
presumption  of  malignancy  any  further  evidence  to  be  obtained  from 
the  histology  of  the  scooped  out  portion  of  tissue  may  be  sought  for 
according  to  the  special  circumstances  of  the  case.  But  after  the 
application  of  the  clinical  test  the  chief  help  will  be  found  in  closely 
watching  the  changes  which  take  place  in  the  wound,  and  these  are 
sufficient  evidence  in  every  case  in  which  malignant  disease  of  the  cervix 
might  possibly  occur. 

When  the  other  points  on  which  a  diagnosis  in  the  early  stages  may 
depend  are  under  discussion  we  still  occasionally  hear  of  Spiegelberg's 
criteria.  These  were  (1)  a  closer  adhesion  of  the  mucous  covering  of  the 
j)ortio  to  the  parenchyma  in  the  case  of  malignant  disease;  and  (2)  the 
difficulty  of  dilating  the  cervix  affected  with  any  cancerous  process  by 
means  of  tents,  and  the  continuance  of  the  hardness  after  dilatation, 


MALIGNANT  DISEASES   OF  THE    UTERUS  683 

simple  induration  disappearing  under  the  softening  influence  of  the  tents. 
This  opinion  has  not  received  much  support,  although  it  has  been  much 
quoted  and  discussed.  It  will  probably  be  considered  quite  sufficient 
guidance  to  their  contemporaries  to  say  that  Winckel  and  Gusserow 
consider  the  criteria  altogether  illusory. 

When  we  come  to  consider  the  local  conditions  and  appearances 
which  may  give  rise  to  suspicion  of  malignant  disease  of  the  vaginal 
portion  or  cervix,  while  the  general  state  of  health,  which  may  be 
deteriorated,  does  not  exclude  the  possibility  of  malignancy,  the  most 
common  case  for  doubt  is  that  of  chronic  cervical  catarrh,  with  laceration, 
ectropium,  and  extensive  "  erosion."  Still  further,  if  in  such  a  case  there 
be  also  present  chronic  retroflexion,  resulting  from  injury  in  parturition 
followed  by  subinvolution,  there  will  be  considerable  added  hypertrophy 
and  other  changes  of  the  posterior  lip.  When  the  results  produced  by 
all  those  factors  are  present  in  the  same  case  the  nearest  approach  to 
malignant  disease  which  we  know  of  is  reached.  This  is  the  sort  of 
case  in  which  doubts  which  are  not  to  be  cleared  up  by  rest,  temporary 
medication,  scarification,  and  similar  measures,  are  set  at  rest  by  the  use 
of  the  sharp  curette. 

The  next  class  of  case  in  order  of  the  frequency  Avith  which  doubts 
arise  and  mistakes  are  made,  is  that  of  necrosis  of  fibroid  yjolypus  with 
partial  expulsion  from  the  external  os.  Such  cases  are  frequently  sent  to 
the  specialist  for  diagnosis,  and  I  have  seen  a  considerable  number  of  them. 
The  most  recent  was  that  of  a  woman  in  the  last  stage  of  anaemia  and 
sapraemia  owing  to  the  partial  expulsion  of  an  enormous  mass  of  fibro- 
myoma.  The  process  had  been  going  on  for  many  weeks,  and  the  mass 
had  become  partially  necrosed ;  it  thus  permitted  the  flow  through  it  of 
a  large  quantity  of  serum,  which  showed  externally  as  a  turbid,  filthy 
discharge;  malodorous  likewise,  but  not  approaching  in  intensity  the 
smell  of  the  discharge  from  a  cancer  in  the  advanced  stage  Avhich  was 
thus  simulated.  Owing  to  the  retraction  of  the  ring  of  the  os  the  first 
impression  taken  from  superficial  examination  of  the  case  was,  that  a 
large  gangrenous  cancer  mass  represented  the  uterus,  which  was  itself 
fixed  by  infiltration  in  the  pelvis.  The  character  of  the  discharge  and 
something  in  the  history  led  to  a  careful  examination  under  very  un- 
favourable circumstances,  and  the  ring  of  the  external  os  was  discovered. 
This  is  the  diagnostic  feature ;  the  ring  of  the  uterine  tissue  is  found  to 
be  intact,  homogeneous,  and  smooth.  Cases  of  this  class  seldom  present 
more  than  a  momentary  difficulty.  In  all  the  cases  -which  I  have  seen 
it  has  always  been  the  repulsive  appearance  of  the  sloughing  mass  that 
has  led  to  the  erroneous  diagnosis.  An  inexact  clinical  history  in  which 
symptoms  are  accepted  as  occurring  in  the  order  in  which  the  patient 
describes  or  mentions  them,  a  perfunctory  examination  of  the  parts 
that  can  be  brought  into  view,  and  want  of  attention  to  differences  in  the 
appearance  and  smell  of  the  discharge,  which  certainly  does  not  invite 
close  investigation,  are  sufficient  to  keep  up  the  supply  of  cases  in  whicli 
such  mistakes  in  diagnosis  are  made. 


6S4  SYSTEM  OF  GYNAECOLOGY 

In  the  more  advanced  stages  of  cancer  of  the  cervix  the  fact  that  a 
malignant  disease  exists  is  as  obvious  as  in  advanced  cancer  of  the  breast; 
or  in  diffuse  ulcerating  and  offensive  epithelioma  of  the  vulva.  Occasion- 
ally, though  rarely,  we  see  malignant  ulceration  of  the  cervix  with  com- 
paratively little  discharge  and  comparatively  little  discoloration.  The 
margin  of  the  ulceration  is  as  definite  to  touch  and  sight  as  that  of  a 
soft  venereal  iilcer  of  the  labium.  In  such  cases  the  question  always 
arises.  Is  the  disease  malignant  or  specific  ?  Much  library  writing  has 
been  devoted  to  the  differentiation  in  such  cases  between  cancer  and 
syphilis,  ^[y  experience  of  English  practice  leads  me  to  the  conclusion 
that  syphilitic  ulceration  of  the  vaginal  portion  of  the  uterus  is  among 
the  rarest  of  the  diseases  of  women.  I  have  several  times  in  the  earlier 
years  of  special  work  suspected  syphilis,  and  temporised  accordingly, 
in  order  to  see  the  effects  of  general  and  local  antisyphilitic  treatment ; 
but  in  not  one  single  case  has  the  ulceration  turned  out  to  be  other  than 
malignant.  There  can  be  no  doubt,  however,  that  a  real  difficulty  might 
arise  owing  to  the  extent  of  ulceration  sometimes  produced  by  syphilis 
in  elderly  subjects  with  constitution  ruined  by  other  causes  as  well. 
The  difficulty  may  be  increased  by  the  fact  that  a  history  of  syphilis  is 
to  be  found  in  cases  of  well-marked  and  unmistakable  epithelioma,  with 
a  frequency  not  to  be  accounted  for  by  mere  coincidence.  Winckel  says 
the  difiiculty  is  so  great  in  some  cases  that  experienced  specialists  in 
venereal  diseases  have  sent  patients  to  him  for  his  opinion.  Obviously 
under  such  circumstances  there  is  no  simple  infallible  and  universally 
applicable  rule.  The  syphilitic  lesions,  early  and  late,  do  not  necessarily 
involve  the  os  externum  —  malignant  disease  always  does.  The  syphilitic 
ulcer  extends  towards  the  os,  the  malignant  ulcer  from  it  —  either  over 
the  free  surface  of  the  vaginal  portion,  or  upwards  in  the  cervical  canal. 
The  syphilitic  lesion  has  little  tendency  to  bleed,  and  is  not  friable ;  the 
malignant  lesion  differs  from  it  in  both  these  respects. 

A  detailed  history  of  the  case,  including  the  dates  of  syphilitic  mani- 
festations, the  appearance  of  the  ulcer  when  clean,  permitting  close 
inspection  of  the  points  that  make  for  malignancy  or  otherwise,  and  the 
immediate  effects  of  treatment,  should  make  diagnosis  possible  even  in 
the  most  ol)SCure  case  without  much  loss  of  time. 

Some  Continental  writers  make  much  of  the  difference  between 
papillary  malignant  disease  of  the  cervix  and  pointed  condyloma.  No 
advantage  can  result  from  the  accumulation  of  distinctions  and  differ- 
ences of  such  small  account  from  the  practical  standpoint.  I  doubt  if  any 
man  ever  saw  a  case  of  condyloma  affecting  the  cervix  uteri,  for  example, 
in  a  pregnant  woman,  in  wliich  condylomas  were  not  also  obvious  in 
the  vagina,  on  the  vulva,  perineum,  or  even  in  the  groins ;  and  if  any 
practitiontu-,  d(;siring  to  be  pedantically  and  logically  correct  in  his 
diagnosis,  imagines  there  could  be  any  question  in  a  case  of  condyloma 
as  to  tlie  nature  of  the  disease,  the  careful  separation  of  the  elements  of 
a  i)apillaiy  condylomatous  mass  or  tuft,  and  the  inspection  of  the  rela- 
tions of  tliese  elements  to  one  another,  to  the  common  ])ortion  at  the 


MALIGNANT  DISEASES    OF   THE    UTERUS  685 

base,  and  the  relation  of  that  base  to  the  intact  underlying  cutaneous  or 
mucous  surface,  must  set  his  mind  at  rest.  He  will  note,  moreover,  the 
results  of  keeping  the  parts  clean  with  an  astringent  antiseptic,  the 
effect  of  cutting  away  some  of  the  tufts,  of  the  application  of  nitric 
acid  to  a  selected  spot,  and  of  microscopic  examination. 

Cases  have  occurred  in  which  partial  retention  of  products  of  concep- 
tion have  led  to  some  difficulty  in  settling  the  question  of  malignancy. 
A  shred  of  placenta,  or  a  plug  of  decidual  tissue  sticking  in  the  os 
externum,  has  been  supposed  to  be  cancer,  and  conversely.  When  prod- 
ucts of  conception  are  retained,  and  partly  visible  through  the  ring  of 
the  OS  externum,  there  is  something  in  the  colour  and  consistency  of 
the  healthy  os  all  round  the  ring  which  is  unmistakable.  There  may 
be  ugly  debris,  some  haemorrhage,  or  sanious  and  evil-smelling  discharge ; 
but  the  suspected  substance  is  free  to  be  lifted  away  with  forceps,  and 
the  uterine  substance  is  not  irregular  to  the  touch :  it  is  homogeneous, 
and  it  is  healthy  in  colour.  But  the  chief  aid  to  differential  diagnosis 
in  such  a  case  is  a  clear  detailed  clinical  history ;  when  such  a  history 
is  obtained  the  diagnosis  is  complete. 

Fror/nosls.  — The  prognosis  in  cases  of  cancer  of  the  vaginal  portion 
or  cervix  uteri  cannot  now  be  laid  down  on  the  old  considerations  of  the 
causes  of  death  in  such  cases,  and  the  probable  duration  of  life  while 
these  causes  are  doing  their  work  without  interference. 

Prognosis  now  depends  upon  what  can  be  done ;  and  what  is  prac- 
ticable and  beneficial,  and  what  is  impracticable  and  harmful,  depends 
upon  the  stage  of  development  Avhich  the  disease  has  reached,  and  to 
some  extent  upon  the  special  area  affected. 

We  first  think  of  operation.  If  vaginal  hysterectomy  is  feasible,  we 
estimate  the  risk  to  life  from  the  operation,  and  the  possible  permanent 
or  temporary  immunity  from  recurrence.  These  are  questions  which  can 
be  best  dealt  with  under  the  head  of  Results  of  Operation.  We  have 
only,  therefore,  to  consider  the  inoperable  cases.  AVe  knoAv  that  here  a 
fatal  termination  is  inevitable,  and  we  must  consider  Avhether  there  are 
any  ineasures  which  may  appreciably  retard  the  progress  of  the  disease 
and  diminish  the  sufferings  of  the  patient.  By  this  time  the  uterus  is 
fixed,  or  there  is  such  obvious  lymphatic  infection  that  extirpation  would 
be  useless,  even  if  practicable.  We  must  then  consider  mainly  the  fol- 
lowing points  all  brought  out  under  symptoms  and  clinical  course: 
(i.)  Is  the  disease  of  long  standing  according  to  the  data  obtainable  ?  If 
the  symptoms  can  be  traced  back  to  a  longer  than  average  time,  then  tlie 
progress  of  the  disease  is  slow  ;  if  it  is  of  comparatively  recent  date,  the 
course  is  rapid,  and  the  prognosis  bad  in  proportion,  (ii.)  Is  the  cancerous 
cachexia  established  ?  If  so,  then  some  complication  may  occur  at  any 
time,  haemorrhage,  septicaemia,  thrombosis,  or  some  other  such  grave  con- 
dition with  its  dangers,  (iii.)  Are  there  any  indications  of  embarrassment 
of  the  kidneys  ?  If  so,  an  opinion  as  to  the  probable  length  of  life  of 
the  patient  cannot  be  too  guarded.  We  have  no  means  of  ascertaining 
the  exact  extent  of  the  changes  which  are  bringing  on  ura?mia.    (iv.)  The 


6S6  SYSTE^f  OF  GYNECOLOGY 

age  of  the  patient  lias  usually  some  relation  to  the  rate  of  gro'wth :  the 
younger  the  patient  the  worse  the  prognosis.  To  this  rule,  however,  the 
exceptions  are  numerous,  (v.)  Does  the  patient  take  nourishment  to 
the  average  amount  in  such  cases  ?  It  is  obvious  that  if  no  specially 
threatening  complication  exist,  the  fatal  end  from  marasmus  must  be 
hastened  or  delayed  according  to  the  patient's  power  of  assimilating  food, 
(vi.)  Can  the  parts  be  kept  in  a  tolerably  aseptic  condition  ?  If  there  be 
a  cavity  in  the  cervix,  and  if  the  body  of  the  uterus  and  the  vagina  be  not 
involved,  the  ulceration,  and  consequently  the  sapraBmia,  can  be  modified. 
In  some  cases,  owing  to  descending  growths  in  the  vagina,  the  chief  seat 
of  the  disease  cannot  be  reached.  The  success  of  some  of  the  palliative 
methods  of  treatment  shows  that  the  progress  of  the  disease  can  be 
greatly  modified  by  the  use  of  the  curette  and  antiseptics. 

Treatment  of  Cancer  of  the  Portio  Vaginalis  and  Cervix  Uteri.  —  When 
a  disease  of  the  uterus  is  diagnosed  as  malignant,  the  question  at  once 
arises :  Is  it  operable  or  inoperable  ? 

If  in  a  case  of  cancer  of  the  portio  or  cervix  the  uterus  is  quite  mova- 
ble, and  on  examination  it  is  found  that  no  considerable  invasion  of  the 
broad  ligament  or  sacro-uterine  folds  has  occurred,  then  the  treatment 
in  our  present  state  of  knowledge  is  radical  operation. 

If  there  is  lymphatic  infection,  and  considerable  or  complete  fixation 
of  the  uterus,  the  case  belongs  to  the  inoperable  class. 

Even  when  the  uterus  itself  is  in  a  condition  to  make  operation  other- 
wise feasible  there  may  be  some  local  complication  or  some  general  con- 
dition to  make  the  radical  operation  unjustifiable. 

In  all  operable  cases  the  first  question  to  be  answered  is  whether 
total  extirpation  per  vaginam  be  not  the  best  method  of  treatment. 

Total  Extirpation  of  the  Uterus.  —  The  operation  may  be  undertaken 
at  one  or  other  of  two  stages  in  the  development  of  the  disease.  In  the 
first  place,  the  object  sought  is  the  entire  ablation  of  the  affected  organ, 
including  surrounding  portions  of  vagina  and  parametrium  which  show 
no  trace  of  invasion  by  the  disease.  The  tissue  operated  upon  must  be 
sound  throughout.  Such  are  the  cases  in  which,  Avhen  the  operation  is 
performed  at  a  very  early  stage,  and  the  patient  survives  the  danger 
of  the  surgical  procedure,  there  is  ground  for  confident  hope  that  she 
is  x-»erinanently  relieved  of  her  troubles. 

In  the  second  place,  the  operation  may  be  undertaken  Avith  advantage 
even  if  there  be  some  slight  interference  with  the  movements  of  the 
uterus,  and  the  broad  ligaments  or  sacro-uterine  folds  can  be  felt  to  be 
more  prominent  and  better  defined  than  in  perfect  health.  In  such  cases 
there  is  some  additional  difficulty  in  the  early  stages  of  the  operation ; 
but  the  remote  results  are  so  satisfactory  as  not  only  to  justify,  but 
to  demand  operative  treatment.  There  is  little  ground  for  expecting  a 
permanent  cure  in  such  cases.  The  disease  will  recur  at  a  more  or  less 
remote  date,  Vjut  the  immediate  advantages  to  the  patient,  and  the  diminu- 
tion in  the  sufferings  of  the  late  stage  of  the  disease,  when  recurrence 
has  taken  place,  are  such  as  greatly  to  outweigh  the  danger  and  distress 


MALIGNANT  DISEASES   OF   THE    UTERUS  687 

of  operation.  These  are  usually  cases  in  which,  owing  to  delay  on  the 
patient's  part  in  seeking  medical  advice,  or  owing  to  want  of  promptness 
and  precision  in  diagnosis  on  the  part  of  the  practitioner,  the  disease  has 
been  allowed  to  make  considerable  progress.  The  vaginal  portion  may 
have  assumed  the  condition  of  a  large  hypertrophic  and  superficially 
ulcerating  mass ;  or  it  may  have  almost  completely  disapjieared  owing  to 
the  progress  of  ulceration  within  the  cervical  canal,  and  yet  the  uterus  may 
not  be  completely  fixed.  There  may  be  obvious  indications  of  deterioration 
in  the  patient's  general  health  owing  to  haemorrhage  and  other  discharges, 
and  the  inability  to  take  sufficient  nourishment.  The  sanious  or  turbid 
serous  discharge  may  have  become  so  profuse  and  offensive  as  to  be  a  source 
of  distress  to  the  patient ;  but  while  the  pain  is  still  inconsiderable,  and  the 
movements  of  the  uterus  are  but  just  appreciably  embarrassed,  there  is 
every  reason  to  expect  a  favourable  result  from  radical  surgical  treatment. 
When  vaginal  extirpation  has  been  decided  upon,  whatever  the  modi- 
fication of  the  operation,  the  necessary  instruments  and  appliances  are 
for  the  most  part  the  same.  The  patient,  after  being  angesthetised,  is 
placed  in  the  lithotomy  position  with  the  hips  projecting  over  the  mar- 
gin of  a  suitable  operating  table.  The  uterus  is,  in  my  experience,  best 
exposed  by  the  use  of  Auvard's  weighted  speculum  with  a  comparatively 
short  blade.  As  the  instrument  is  self-retaining,  it  releases  the  hand  of 
an  assistant  for  other  purposes,  and  in  this  respect  it  is  greatly  superior  to 
the  short  and  broad  speculum  which  was  formerly,  or  may  be  still,  in  gen- 
eral use  in  Germany.  Whatever  measures  may  have  been  previously 
adopted  to  cleanse  and  disinfect  the  parts,  it  is  now  advisable  to  cleanse 
them  thoroughly  once  more  before  making  any  incision  or  wound.  Some 
operators  insist  upon  the  preliminary  use  of  the  curette  and  cautery  as 
essential.  The  anterior  lip  of  the  vaginal  portion,  where  the  tissue  is 
healthy,  should  be  seized  with  a  suitable  volsella  and  the  movements  of 
the  uterus  finally  tested.  The  use  of  the  volsella  also  enables  the  opera- 
tor to  convey  any  necessary  movements  to  the  projecting  vaginal  portion 
so  as  to  permit  him  thoroughly  to  cleanse  the  parts.  The  cleansing  may 
be  very  well  effected  by  thoroughly  swabbing  and  rubbing  the  parts  with 
dossils  of  cotton  wool  soaked  in  a  solution  of  perchloride  of  mercury  of 
1  in  2000.  Not  only  the  uterus  and  vagina  should  be  thus  thoroughly 
washed,  but  all  the  external  parts  also,  from  the  mons  veneris  downwards  ; 
special  attention  being  given  to  the  folds  of  the  labia,  both  minor  and 
major.  If  there  be  any  friable  material  about  the  ulcer  or  growth  of  the 
cervix,  such  shreds  of  tissue  must  be  thoroughly  disinfected  and  rubbed 
away  by  means  of  the  swabs.  It  may  be  even  advisable  to  use  the 
curette,  but  such  a  proceeding  is  seldom  necessary.  If  the  disease  have 
assumed  the  hj^  pertrophic  form  it  may  be  necessary  to  begin  by  rapidly 
cutting  aAvay  with  scissors  sufficient  of  the  new  growth  to  make  room  for 
manipulation  and  to  disembarrass  the  proceedings  ;  the  bleeding  vessels 
being  rapidly  seized  by  suitable  pressure  forceps.  This  preliminary  step 
is  almost  always  necessary  in  dealing  with  operable  cases  of  cauliflower 
excrescence.     In  the  majority  of  cases,  however,  it  is  usually  practicable, 


688  SYSTEiM  OF  GYNECOLOGY 

and,  if  so,  preferable  to  proceed  until  the  uterine  arteries  have  been 
ligated,  and  the  vagina  and  the  lower  portion  of  the  parametrium  cut, 
before  removing  any  embarrassing  mass ;  as  it  can  then  be  cut  away 
without  any  considerable  haemorrhage.  Before  beginning  with  scalpel 
or  scissors  it  is  advisable  to  ascertain  the  relations  of  the  bladder  to  the 
cervix,  and  this  is  done  by  a  suitable  sound. 

There  are  many  modifications  of  the  beginning,  and  of  every  sepa- 
rate successive  stage  of  the  operation  of  vaginal  hysterectomy.  Every 
operator  appears  to  have  a  method  of  his  own.  In  my  opinion,  it  is  best 
to  begin  with  the  anterior  vaginal  wall,  just  where  the  vagina  is  reflected 
off  the  vaginal  portion,  if  the  tissue  be  so  thoroughly  healthy  that  a 
margin  of  normal  vagina  can  be  removed  with  the  uterus.  The  ligatures 
should  be  used  throughout  in  order  to  prevent  the  loss  of  blood  which 
results  from  simple  incision,  for  the  patient  is  usually  .anaemic.  To 
economise  time  a  special  needle  may  be  use'd  for  the  proper  placing 
of  the  ligatures.  It  consists  of  a  strong  metal  instrument,  shaped 
like  an  aneurysm  needle  but  without  eye,  and  with  a  point  like  a  blunt 
Hagedorn  needle.  There  is  a  notch  for  catching  the  ligature  not  far 
from  the  point  on  the  convexity  of  the  rim.  The  instrument  should  be 
short  and  strong. 

While  the  uterus  is  firmly  dragged  upon  by  means  of  a  suitable 
volsella,  and  held  steady  by  an  assistant,  the  operator  passes  the  needle 
transversely  through  a  considerable  portion  of  the  healthy  anterior  vaginal 
wall,  so  as  to  occupy  as  nearly  as  possible  the  central  third.  An  assistant 
puts  the  loop  of  suitable  silk  ligature  into  the  notch  of  the  needle,  the 
needle  is  drawn  back,  and  the  ligature,  thus  brought  through,  is  tied  by 
the  operator.  The  uncut  ends  can  now  be  held  up  by  one  of  the 
assistants,  and  the  silk  acts  to  some  extent  as  a  retractor.  The  vagina 
is  cut  through  with  scalpel  or  scissors  so  as  to  leave  a  sufficient  button 
held  by  the  ligature.  Care  should  now  be  taken  to  ascertain  that  the  fin- 
ger nail  or  the  handle  of  the  scalpel  can  be  passed  into  the  cellular  tissue 
between  the  vagina  and  uterus.  A  portion  of  the  vagina  should  again  be 
taken  up  on  each  side  in  the  same  way,  and  cut  as  before,  the  separation 
of  the  vaginal  wall  and  uterus  beiiig  carried  laterally  by  breaking  down 
the  loose  tissue  with  the  index  finger,  or  suitable  implement.  In  patients 
who  are  not  anaemic  a  little  time  is  saved  by  cutting  through  this  portion 
of  vagina,  by  scalpel  or  scissors,  without  previous  ligation.  The  uterus  is 
now  drawn  sideways  —  say  towards  the  left  —  in  order  to  secure  the  para- 
metrium on  the  right  side,  including  the  uterine  vessels.  Here  it  is  usually 
advisable  to  employ  a  retractor  to  prevent  the  side  of  the  vagina  and  the 
labium  from  obscuring  the  field  of  operation.  The  needle  is  now  passed 
well  down  into  the  parajnetrium,  ])eginning  at  the  angle  of  the  portion  of 
the  vagina  already  cut,  and  coming  out  symmetrically  at  the  corresj^ond- 
ing  point  posteriorly.  If  care  be  taken  to  keep  close  to  the  uterus,  while 
at  the  same  time  the  needle  is  brought  out  through  sound  vaginal  tissue 
posteriorly,  then  the  ligature  which  has  thus  been  introduced  may  be 
tied,  and  the  vagina  and  parametrium  cut  through,  to  the  extent  of  the 


MALIGNANT  DISEASES   OF  THE    UTERUS  6S9 

tissues  ligated,  with  precision  and  confidence.  The  same  proceeding  is 
carried  out  on  the  opposite  side.  The  uterus  in  a  suitable  case  may  now 
be  dragged  much  lower,  and  the  complete  separation  of  the  cervix  from 
the  bladder  should  be  carried  out  by  carefully  working  with  the  tip  of 
the  index  finger  from  the  middle  line  towards  each  side.  The  colour 
and  the  firmness  of  the  uterine  tissue  should  not  leave  the  operator  in 
doubt  wliether  he  has  hit  upon  the  cellular  tissue  at  the  proper  depth. 
Before  the  peritoneum  of  the  vesico-uterine  fold  is  cut  through  the 
parts  should  be  thoroughly  examined  for  bleeding  points,  and  all 
haemorrhage  suppressed  by  suitable  means.  It  may  be  necessary  to  use 
ligatures  or  pressure  forceps  temporarily.  It  seems  to  me  a  prefera- 
ble rule  to  open  into  the  peritoneum  anteriorly,  rather  than  to  cut 
first  into  Douglas'  space.  The  anterior  fold  is  easily  opened  by  tear- 
ing or  cutting  at  the  stage  of  the  operation  now  reached,  and  a  sponge 
of  suitable  size  with  a  piece  of  silk  thread  or  silver  wire  attached  (so 
as  to  prevent  it  from  being  lost  amongst  the  intestines),  is  passed  through 
the  opening.  It  is  now  time  to  open  Douglas'  space.  The  posterior 
vaginal  wall  is  ligated  and  cut  through  in  the  same  way  as  before. 
Whether  the  anterior  vaginal  wall  be  ligated  before  cutting,  or  be  merely 
incised,  it  is  always  advisable  to  tie,  and  then  to  cut  the  posterior  vaginal 
wall  in  sections,  or  to  use  pressure  forceps,  as  it  is  so  much  more  vascular 
than  the  anterior  wall.  The  cellular  tissue  is  then  broken  down  as  far  up- 
ward as  possible  upon  the  posterior  surface  of  the  cervix  before  tearing 
through  or  cutting  the  peritoneum.  The  deeper  the  cellular  tissue  can  be 
torn  before  the  peritoneum  is  cut  the  broader  is  the  future  healing  surface 
obtained.  An  opening  is  made  through  the  peritoneum  and  extended  later- 
ally, and  a  sponge  is  passed  through  as  in  front.  The  uterus  is  now  sepa- 
rated from  all  the  structures  around  it  with  the  exceptions  of  portions  of 
the  two  broad  ligaments.  This  is  the  stage  at  which  the  clamp  is  put  on  b}^ 
those  who  prefer  the  clamp.  If  the  uterus  be  considerably  enlarged,  it  may 
be  necessary  to  use  more  than  one  clamp  on  each  side.  When  the  clamp 
is  secured  the  broad  ligament  is  cut  through  on  each  side,  leaving  sufficient 
tissue  for  the  clamp  to  maintain  its  hold.  Then  the  uterus  is  drawn 
out.  When  the  ligature  is  used  the  needle  is  made  to  mark  off  a  suita- 
ble amount  of  tissue  in  the  remainder  of  a  broad  ligament ;  the  liga- 
ture is  drawn  through  and  tied  firmly,  the  ends  being  left  long.  This 
is  repeated  in  stages  upwards  through  the  whole  of  the  broad  ligament 
and  over  the  Fallopian  tube  and  ovarian  ligament ;  and  the  same  thing 
is  repeated  on  the  opposite  side.  When  the  uterus  is  drawn  away  the 
stumps  of  the  broad  ligaments  are  seen  on  either  side,  and  the  sponges 
are  in  the  middle  line  retaining  the  intestines  and  omentum  in  the  pelvis. 
The  sponges  may  or  may  not  be  renewed,  according  to  the  amount  of 
manipulation  that  has  been  necessary,  and  of  the  lueniorrhage  that  has 
occurred ;  but  it  is  best  upon  the  whole  to  renew  them,  so  as  to  ascertain 
whether  luemorrhage  is  going  on  from  any  point.  At  this  stage  in  the 
operation  the  danger  of  prolapse  of  intestine  or  omentum  should  always 
be  guarded  against.     If  the  patient  is  allowed  to  strain  from  sickness 

2  Y 


690  SVSTEAI   OF  GYNj^COLOGY 

there  is  a  real  danger  to  life  from  dislocation  of  bowel,  whicli  may  end 

in  obstruction. 

The  question  always  arises:  Should  the  ovaries  be  removed  or  left? 
As  they  are  seldom  or  never  infected  in  any  way  by  the  disease,  it  is 
not  worth  while  to  complicate  the  operation  by  removing  them  unless 
they  force  themselves  upon  the  operator's  notice  by  becoming  pro- 
lapsed. If  the  patient  has  passed  the  menopause  the  ovaries  are  shriv- 
elled and  atrophic  ;  and  if  she  is  comparatively  young  they  soon  waste 
owing  to  tlie  distal  ligation  of  their  arteries. 

An  important  modification  has  now  to  be  considered.  Should  the 
operation  be  completed  by  merely  packing  in  iodoform  gauze  or  other 
suitable  material  to  close  the  chasm  in  the  pelvic  floor,  or  should  the 
great  wound  be  closed  by  sutures  ?  From  my  early  experience  of  the 
occurrence  of  dislocation  of  intestine  and  consequent  fatal  obstruction, 
and  of  the  occurrence  of  the  distressing  but  not  necessarily  fatal  com- 
plication of  vesical  fistula,  I  believe  it  is  decidedly  the  best  practice  to 
close  the  wound.  The  proceeding  is  of  the  same  kind  as  the  introduc- 
tion of  the  sutures  through  the  abdominal  parietes  in  closing  the  wound 
in  abdominal  section.  Fairly  strong  catgut  or  fine  silk  may  be  passed 
by  means  of  a  suitable  needle  through  the  anterior  vaginal  wall,  very 
superficially  through  the  raw  surface  of  connective  tissue,  and  then 
through  the  torn  anterior  peritoneum;  a  good  hold  being  taken  of 
vagina  and  peritoneum.  The  needle  is  then  passed  posteriorly  through 
the  peritoneum,  which  has  formed  part  of  the  floor  of  Douglas'  sf)ace, 
and  finally  through  the  posterior  vaginal  wall.  The  whole  chasm  in 
the  pelvic  floor  may  be  thus  closed,  with  the  exception  of  the  two  ex- 
tremities through  which  the  long  ends  of  the  ligatures  of  the  broad 
ligament  pass.  These  ligatures  may  be  conveniently  twisted  into  a 
cord  at  each  end,  and  held  out  of  the  field  of  operation. 

After  Olshausen's  success  in  completing  the  operation  by  cutting 
short  the  broad  ligament  ligatures,  and  completely  closing  the  wound  in 
the  pelvis,  I  tried  for  a  time  to  do  without  drainage,  but  found  the  result 
unsatisfactory.  Several  times,  owing  to  unfavourable  symptoms  which 
followed,  it  was  necessary  to  undo  some  stitches  in  order  to  permit  of 
the  escape  of  retained  fluid;  since  then  I  have  always  used  at  least 
one  drain  of  perforated  and  carefully  prepared  rubber  tubing,  which  is 
inserted  into  one  or  other  extremity  of  the  wound.  After  the  with- 
drawal of  the  sponges  a  final  swabbing  of  the  ligatures,  and  of  the 
vaginal  yx'Jcket  which  is  formed  when  the  sutures  are  drawn  tight  and 
tied,  is  now  all  that  is  necessary  before  applying  iodoform  and  iodoform 
gauze  sufficient  to  support  the  pelvic  floor  and  to  act  as  a  drain.  It  is 
not  advisable,  from  the  unfounded  fear  of  prolapse,  to  pack  the  vagina 
very  tight  with  the  gauze.  In  one  case,  at  least,  I  have  seen  very  distress- 
ing symptoms  immediately  following  the  operation,  symptoms  so  severe 
as  to  suggest  intestinal  oljstiiiction,  immediately  nslieved  l)y  removal  of 
the  vaginal  tampon.  If  the  ligatiir(!S  arc  suffi(;ient  in  nu]iil)er  and  firmly 
tied,  there  should  be  no  anxiety  about  primary  or  secondary  haemorrhage. 


MALIGNANT  DISEASES   OF   THE    UTERUS  691 

The  after  treatment  is,  as  a  rule,  extremely  simple:  it  is  almost 
purely  expectant.  If  the  ligature  has  been  used  it  is  not  necessary  to 
interfere  with  the  parts  for  several  days.  There  may  be  at  first  con- 
siderable blood-staining  on  the  external  pad;  if,  however,  there  are 
no  constitutional  signs  of  haemorrhage,  it  is  not  advisable  to  undo  the 
dressings.  The  application  of  the  ice-bag  in  the  iliac  regions,  the  use, 
perhaps,  of  a  hypogastric  pad,  and  the  administration  of  considerable 
quantities  of  warm  neutral  fluid,  will  almost  certainly  stop  or  make 
up  for  too  profuse  drainage.  The  pulse  and  temperature  will  indicate 
whether  the  progress  is  normal  or  whether  complications  threaten ;  in 
most  cases  after  the  first  day  there  is  in  the  repose  and  absence  of 
symptoms  a  suggestion  of  the  normal  puerperium.  Septic  peritonitis 
is  the  danger  at  this  stage ;  fortunately  it  is  not  common  :  when  it 
does  occur  it  may  run  a  very  rapid  course  in  spite  of  irrigation  and 
free  drainage. 

In  elderly  subjects  pain  is  not  much  complained  of ;  but  in  younger 
patients  the  lumbar  pain  may  be  excessively  severe,  and  require  the  ad- 
ministration of  morphia.  There  is  no  evidence  that  morphia  does  the 
patient  any  harm ;  and  there  can  hardly  be  a  question  whether  the  sur- 
geon be  justified  in  leaving  his  patient  to  endure  tortures  which  she  was 
not  led  to  anticipate  when  she  assented  to  tlie  operation.  Whether  mor- 
phia be  administered  or  not,  it  is  advisable  to  stimulate  the  peristaltic 
action  of  the  intestines,  in  order  to  avoid,  if  possible,  the  principal  dan- 
ger not  yet  passed;  namely,  obstruction  of  the  bowels.  After  thirty- 
six  hours  —  Avhen,  if  no  adverse  symptoms  have  arisen,  one  may  say  with 
confidence  that  the  danger  of  septic  peritonitis  is  over  —  the  aperient  may 
be  administered.  I  prefer  one-grain  doses  of  calomel  administered  at 
intervals  of  an  hour,  and  as  many  as  five  grains  may  be  given  in  this 
way  if  no  unfavourable  symptoms  appear.  If  flatus  now  begins  to  pass 
freely  with  the  aid  of  the  rectum  tube  the  danger  of  obstruction  is  also 
at  an  end.  The  aperient  may  be  supplemented  by  the  administration  of 
a  saline ;  and  at  this  stage  I  have  reason  to  prefer  one  or  two  drachms 
of  the  sulphate  of  magnesia  made  into  a  lemon  syrup  and  administered 
warm.  The  drainage  tube  is,  as  a  rule,  of  no  further  use  after  the  first 
three  daj's,  and  it  may  be  withdrawn. 

Towards  the  end  of  the  first  week  there  may  be  some  suppuration; 
and  it  is  well,  if  this  come  on,  to  change  the  dressings  every  day, 
swabbing  the  parts  well  during  the  process  with  a  warm  antiseptic 
solution.  In  the  second  week  the  ligatures  come  away;  occasionally 
it  is  advisable  by  traction  to  anticipate  their  spontaneous  expulsion. 

There  does  not  seem  to  be  any  danger  of  the  occurrence  of  hernia 
owing  to  Aveakness  of  the  pelvic  floor;  it  would  seem  that  after  a  very 
few  days  such  adhesions  are  formed  within  the  pelvis  as  to  prevent  any 
considerable  force  from  acting  on  any  one  point  in  the  cicatrising  wound. 
Nevertheless,  considering  the  need  for  every  possible  advantage  of  physi- 
cal and  mental  repose,  with  efficient  nourishment  and  the  influence  of  the 
best  sanitary  conditions,  I  do  not  think  we  render  our  patients  a  good 


692  SYSTEM   OF   GYA'yECOLOGY 

service  in  hurrying  them  out  of  bed  so  that  we  may  point  to  a  "  record  " 
time  of  operation  and  convalescence.  Most  of  our  cases  are  hospital 
patients,  and  I  always  feel  that  the  longer  we  can  keep  them  and  nurse 
them  the  less  risk  there  is  of  the  recurrence  of  the  disease. 

So  numerous  are  the  modifications  of  this  operation,  that  it  might 
almost  be  said  with  literal  truth  that  each  operator  who  has  done  any 
considerable  number  of  operations  has  called  attention  to  the  advan- 
tages of  some  modification  of  his  own. 

The  method  of  turning  the  uterus  upside  down,  which  was  universal 
at  first,  is  now  given  up.  After  partial  division  of  the  broad  ligament 
on  each  side,  the  manipulations  by  the  volsella  were  carried  out  until 
the  fundus  uteri  could  be  seized  and  dragged  down  through  either 
the  anterior  or  posterior  opening.  The  residt  of  this  manoeuvre  Avas 
to  twist  the  broad  ligaments,  which  could  then  be  tied  in  bulk.  Its 
drawbacks  soon  became  obvious  enough.  The  method  led  more  readily 
than  almost  any  other  to  the  ligation  of  the  ureters,  and  owing  to  the 
mass  of  tissue  tied,  haemorrhage,  from  slipping  of  ligatures,  was  too  fre- 
quent a  result.  Some  slight  modification  of  it,  however,  to  meet  special 
difficulties,  may  be  still  introduced  during  the  operation. 

Among  other  modifications  is  that  of  Fritsch,  who  begins  the  opera- 
tion at  the  sides ;  this  enables  him  to  tie  the  uterine  vessels  at  a  very 
early  stage  of  the  proceedings,  and  to  diminish  hgemorrhage.  It  is  a 
modification  which  can,  no  doubt,  be  very  readily  applied  to  the  less 
advanced  cases. 

The  thermo-cautery  has  been  introduced  by  Sanger  to  divide  the 
vagina  all  round  so  as  to  prevent  hseraorrhage,  and  to  save  the  time 
otherwise  required  to  introduce  the  ligatures.  The  advantages  and 
drawbacks  of  the  introduction  of  the  thermo-cautery  at  this  stage  of 
the  operation  must  be  obvious  to  any  one  who  has  attempted  to  iise  it. 
Mackenrodt  goes  further  still  with  the  use  of  the  cautery ;  he  has  re- 
ported several  cases  in  which  he  trusted  to  the  use  of  the  thermo-cautery 
to  divide  the  tissues  including  vessels  throughout  the  operation.  He  ap- 
pears to  believe  in  it  as  a  safe  and  effective  method  of  operation,  and  he 
claims  for  it  that  recurrence  by  inoculation  is  less  likely  to  take  place. 

The  clamp  is,  however,  the  principal  modification  in  the  operation  of 
extirpation  of  the  uterus.  Its  advantages  are  maintained  mainly  by 
Richelot  and  Pdan  in  France,  by  Landau  and  others  in  Germany.  'JMiere 
are  already  many  inventors  of  clamps  for  which  special  advantages  are 
claimed,  but  at  the  present  time  it  does  not  appear  that  the  clamp  opera- 
tion is  making  headway.  The  clamp  certainly  shortens  the  operation, 
and  it  is  much  easier  with  it  than  with  the  ligature  to  control  ha3mor- 
rhage  from  infiltrated  tissue.  Some  of  the  disadvantages  of  the  clamp, 
however,  are  ol>vious  enough.  It  prevents  the  closure  of  the  wonnd  in 
the  pelvis;  that  is  to  say,  the  completion  of  the  operation.  It  involves 
danger  of  tearing  through  the  tissues  held  by  it,  and  consequently  of 
producing  hgemorrhage.  This  must  always  be  the  case  so  long  as  any 
j)ortion    of   the  clamp   remains   external  in  the  dressings.     Then  the 


MALIGNANT  DISEASES   OF  THE    UTERUS  693 

destruction  of  tissue  by  necrosis,  and  the  interference  with  the  dressings 
on  removal  of  the  clamp,  must  produce  a  distinct  danger  of  septic  in- 
fection. In  some  of  the  cases  reported  the  intestine  had  been  nipped 
by  the  point  of  the  clamp,  which  was  away  beyond  reach ;  this  is  an 
accident  that  should  hardly  occur  in  the  hands  of  a  careful  and  experi- 
enced operator.  To  a  different  class  of  accidents  belongs  the  catching  of 
the  ureters  by  the  clamp,  Avhich  is  said  to  occur  more  frequently  than  in 
the  ligature  operation :  in  any  case  it  is  an  accident  which  may  occur 
in  the  hands  of  the  most  careful. 

Results  of  Total  Extirjxition  jjer  Vaginam.  —  So  numerous  and  volu- 
minous have  been  the  publications  dealing  with  the  results  of  opera- 
tions for  cancer  of  the  uterus  during  the  last  few  years,  that  one  can 
only  select  a  few  reports  as  types  of  their  class,  in  order  to  call  attention 
to  the  practical  conclusions  which  the  perusal  of  many  of  them  suggests. 

A  few  years  ago,  when  the  operation  was  just  beginning  to  gain  a 
footing  in  England,  Dr.  William  Duncan  called  the  attention  of  the 
medical  profession  to  it.  From  his  own  experience,  and  the  results  culled 
from  numerous  publications,  he  came  to  the  conclusion  that  the  operation 
involved  a  mortality  of  25  to  30  per  cent.  This  discouraging  result 
depended  upon  the  fact  that  a  large  number  of  the  operators  had 
only  one  case  to  report.  With  greater  experience  the  results  of  the 
operation  have  marvellously  improved ;  and  they  may  be  considered 
supremely  satisfactory,  even  without  applying  the  illusory  or  impossible 
standard  of  "  the  best  results  of  the  most  experienced  operators." 

If  we  analyse  the  report  of  Krukenberg  already  referred  to, 
we  find,  during  5^  years  ending  April  1891,  a  very  large  propor- 
tion of  the  cases  of  malignant  disease  of  the  uterus  were  considered 
operable:  292  in  924,  or  31 -6  per  cent.  The  292  radical  operations 
were  made  up  in  this  proportion :  235  times  vaginal  h3'sterectomy,  4-4 
times  supravaginal  amputation,  and  13  times  supravaginal  amputation 
after  abdominal  section.  Of  the  radical  operations,  197  were  for  cancer 
of  the  cervix,  with  the  following  results  :  25  died  directly  in  consequence 
of  the  operation,  that  is,  12-7  per  cent.  Recurrence  of  the  disease 
appeared  in  69  within  one  year.  Pyometra  was  the  worst  complication, 
nearly  all  the  cases  being  fatal  from  infection.  Nine  of  the  patients 
were  alive  and  well  at  the  end  of  nine  years.  Important  information 
bearing  on  prognosis  is  given  regarding  48  cases  which  remained  free 
from  recurrence,  and  55  in  which  the  disease  had  reappeared,  (i.)  Of  cases 
of  carcinouia  of  the  mucosa  of  the  cervix  in  the  early  stage,  recurrence 
took  place  in  33-3  per  cent,  (ii.)  Of  cases  of  superficial  ulceration  of  the 
portio,  there  was  recurrence  in  36-4  per  cent,  (iii.)  Of  small  cauliflower 
excrescence,  recurrence  in  42-4  per  cent,  (iv.)  Of  advanced  carcinoma  of 
the  cervical  mucous  membrane,  recurrence  in  58-8  per  cent,  (v.)  Of 
carcinoma  involving  the  walls  of  the  cervix,  recurrence  in  00  per  cent. 
(vi.)  Of  greatly  developed  cauliflower  excrescence  of  the  portio,  recur- 
rence in  02 -5  per  cent,  (vii.)  Of  deep  ulceration  of  the  cervix,  begin- 
ning as  epithelioma  of  the  portio,  recurrence  in  80  per  cent. 


694-  SYSTEM    OF  GYNECOLOGY 

"With  regard  to  influences  favouring  recurrence  nothing  definite  ap- 
pears from  the  figures  except  the  site  and  extent  of  the  disease.  Upon 
the  whole,  women  over  45  years  of  age  showed  less  frequent  recurrence 
than  women  under  45. 

Among  figures  for  a  period  practically  the  same  we  have  those  of 
Terrier  and  Hartmann.  In  36  cases  there  was  a  mortality  from  the 
operation  equal  to  23-5  per  cent.  Seven  patients,  at  a  sufficiently 
remote  period,  were  considered  permanently  cured.  They  put  down 
recurrences  at  70  per  cent,  and  cures  at  30  per  cent. 

Eichelot  (38),  publishing  the  results  of  four  years'  work  in  18S2, 
shows  a  greatly  diminished  mortality,  the  causes  of  which  may  be  inferred 
from  the  facts.  He  performed  225  operations,  with  11  deaths ;  that  is, 
5  per  cent.  He  used  the  clamp  exclusively,  and  argues  in  its  favour. 
He  had  no  haemorrhage  either  primary  or  secondary.  He  does  not  think 
the  ureters  are  in  greater  danger  from  the  clamp  than  from  the  ligature  ; 
he  never  caught  intestine  with  his  instrument ;  and  he  does  not  believe 
that  the  clamp  narrows  the  field  of  operation.  As  a  drawback  he  men- 
tions that  the  clamp  is  more  painful  to  the  patient.  ■ 

Biirkle,  in  an  inaugural  dissertation  in  1892,  gives  a  summary 
of  the  operations,  mostly  German,  up  to  the  date  of  publication.  He 
mentions  273  operations  of  total  extirpation  with  a  mortality  of  10  per 
cent.  Among  the  causes  of  death  were :  septic  peritonitis  in  22  cases  ; 
ileus  in  2  cases  ;  and  hsemorrhage,  pneumonia,  and  heart  failure  in  one 
case  each.  Among  the  incidents  of  operation  were :  incision  of  vagina 
and  perineum,  5  times ;  pyosalpinx,  4  times ;  pyometra,  17  times  with 
loss  of  7  patients ;  complications  with  myomata  in  9  cases ;  ovarian 
tumour  of  considerable  size,  in  5  cases;  injury  to  the  ureter  in  4  cases. 

From  an  account  of  Kaltenbach's  work  at  Halle,  published  by 
Bucheler,  we  see  how  improvement  went  on  in  method  as  well  as  in 
results.  The  chief  modification  in  Kaltenbach's  method  was  suturing  of 
the  peritoneum  in  the  pelvis ;  he  also  employed  antiseptics  in  a  very 
stringent  fashion.  The  total  number  of  operations  was  159,  and  the 
mortality  was  at  the  rate  of  3-9  per  cent.  This  was  by  a  long  way 
the  lowest  mortality  at  the  time  of  the  completion  of  the  work.  Among 
the  accidents  in  the  course  of  operation  were  injury  to  the  bladder,  pro- 
ducing fistula;  injury  to,  or  tying  the  ureters,  and  the  production  of  a 
faecal  fistula :  once  a  sponge  was  left  within  the  ])elvis.  The  number 
of  operations  for  cancer  of  the  cervix  was  134.  There  were  free  from 
recurrence  at  the  time  of  publication,  19 ;  and  four  had  remained  free 
for  over  three  years,  with  fatal  recurrence  afterwards.  The  ligature 
was  used  exclusively  in  operation. 

In  1894,  Al)el  of  lierlin  jjublished  a  paper  on  total  extirpation, 
which  was  chiefly  an  argument  in  favour  of  the  clamp.  He  mentioned 
that  he  and  Landau,  who  also  uses  the  clamy)  exclusively,  had  a  mortality 
of  5"4  per  cent  over  a  total  material  of  93  cases. 

Zweifel's  mortality  up  to  the  same  time  was  almost  exactly  5  per  cent, 

Mangiagalli  has  given  an  account  of   the  immediate   and   remote 


MALIGNANT  DISEASES   OF   THE    UTERUS  695 

results  of  his  operations  with  such  comments  and  quotations  that  a 
summary  of  his  contributions  might  completely  serve  our  purpose.  He 
gives  an  analysis  of  his  cases  according  to  site  of  the  disease,  the  exten- 
sion of  the  disease,  and  the  method  of  operating,  whether  by  ligatui-e 
with  closure  of  wound,  or  without  closure  of  wound,  or  by  the  clamp. 

For  example :  in  carcinoma  of  the  cervix :  — 

Without  diffusion  to  vagina,  etc.,  46  cases,  45  recoveries,  1  death, 
mortality  2-17. 

With  diffusion  to  vagina,  etc.,  36  cases,  30  recoveries,  6  deaths, 
mortality  16-66. 

In  his  1st  class  —  operations  by  ligature  without  suture  of  the 
wound  —  there  were  23  cases,  20  recoveries,  3  deaths,  that  is  a  mortality 
of  13-04  per  cent. 

In  the  2nd  class  —  operations  by  ligature  with  suture  of  the  pelvic 
wound  —  40  cases,  38  recoveries,  2  deaths ;  a  mortality  of  5  per  cent. 

In  the  3rd  class  —  use  of  the  clamp  —  25  cases,  22  recoveries,  3  deaths, 
a  mortality  of  12  per  cent. 

Mangiagalli  concludes  that  the  mortality  from  extirpation  for  cancer 
of  the  body  is  greater  than  for  cancer  of  the  cervix ;  but  his  material  is 
perhaps  too  small  for  generalisation.  One  conclusion  brought  out  by 
his  figures  on  which  he  lays  much  stress  is :  ''  The  most  important 
element  in  the  prognosis  of  vaginal  hysterectomy  for  cancer  of  the  cer- 
vix is  the  extent  of  the  diffusion  to  the  vagina  and  parametrium." 

In  discussing  the  remote  results  the  author  accepts  provisionally  the 
criticism  that  the  disease  may  be  considered  cured  if  there  be  no  recur- 
rence within  two  years ;  and  shows  that,  according  to  the  way  in  which 
deductions  Avere  made,  his  results  would  be  at  the  rate  of  38  to  44  per 
cent  of  cures.  The  German  operations  selected  show  from  36  to  64  per 
cent  of  such  cases.  In  many  of  the  contributions  on  the  subject  of 
results  there  appears  to  be  a  tendency  to  hold  a  sort  of  inquest  on  every 
death,  and  to  draw  up  percentages  according  to  the  verdicts  obtained 
after  explaining  away  the  causes  of  death. 

Richelot  (39)  gives  the  results  of  his  operative  work  down  to  August 
1895.  He  published  an  account  of  274  cases  of  vaginal  hysterectomy 
dating  to  the  end  of  1893  with  the  results,  namely  — 

44  cases  of  uterine  cancer  ....  3  deaths. 

61       ,,         pelvic  suppuration       .  .  .  5      ,, 

126       ,,         non-suppurative  affection     .  .  5      ,, 

43       ,,         uterine  fibroma  .  .  .  In 

The  total  mortality  is  5-10  per  cent. 

From  the  end  of  1893  to  the  1st  of  August  1895  he  had  performed 
202  additional  operations  :  — 

14  cases  of  uterine  cancer  ....  3  deaths. 

66       ,,         pelvic  suppuration       .  .  .  3      ,, 

89       ,,         non-supinirative  affection     .  .  2      ,, 

33       ,,         uterine  librouia  .  .  .  2      ,, 


696  SYSTEM   OF  GYNECOLOGY 

Still  a  total  mortality  of  practically  5  per  cent,  but  with  a  very  high 
mortality  for  cancer  operations.  The  figures  for  operations  undertaken 
on  other  grounds  are  given  to  indicate  how  little  inherent  danger  there 
may  be  in  the  operation  itself ;  any  further  remark  would  be  irrelevant. 

After  such  statistics  it  is  much  of  a  drop  to  come  to  my  own  fig- 
ures. I  began  to  operate  early  in  the  history  of  vaginal  hysterectomy 
(September  1882),  and  I  have  operated  when  I  anticipated  an  advantage 
for  the  patient,  after  alloAving  for  risk,  operative  distress,  and  injury  to 
the  general  health.  My  cases  have  consequently  included  a  considerable 
proportion  where  some  invasion  of  the  vagina  and  parametrium  existed. 
It  is  some  comfort  to  find  that  others,  witness  Mangiagalli,  have  had  even 
a  higher  mortality  in  such  cases.  The  tendency  of  isolated  operators  is, 
I  imagine,  to  try  operation  on  cases  too  far  advanced,  in  the  hope  of 
giving  the  patient  a  chance.  It  is  only  the  close  observation  of  recent 
years  that  has  shown  how  futile  such  operative  work  must  be. 

My  first  10  cases  were  published  in  the  Practitioner  in  1889 ;  4  of 
the  patients  died,  giving  a  mortality  of  40  per  cent.  Up  to  the  time  of 
beginning  to  close  the  pelvic  wound  in  1890,  I  had  operated  another  12 
times  with  1  death. 

From  the  time  of  closing  the  wound  completely  I  had  2  deaths  in 
1890,  and  so  I  began  drainage  as  well  as  closure.  From  the  time  of 
drainage  to  the  end  of  July  1894,  there  was  a  further  series,  making  45 
cases  "with  7  deaths,  a  mortality  of  15  per  cent.  Up  to  that  time  also 
there  were  15  private  cases  of  cancer  of  the  portio  and  cervix,  with  1 
death,  making  a  mortality  of  6|-  per  cent.  Partly  before  and  partly 
since  July  1894  there  have  been  5  cases  of  cancer  of  the  body.  All 
these  patients  recovered  from  the  operation,  and  all,  so  far  as  is  known, 
are  still  free  from  recurrence. 

Considering  the  physical  wrecks  some  of  the  patients  were  at  the 
time  of  operation,  and  the  stage  which  the  disease  had  reached,  we  can 
only  wonder  that  even  this  modified  success  was  achieved.  The  opera- 
tions are  all  given  without  deduction  on  account  of  any  process  of 
"inquest"  on  fatal  cases.  But  for  the  operation  no  patient  would 
have  died  at  the  time  she  did. 

Few  cases  have  been  seen  in  the  most  favourable  stage  for  operation, 
hence  the  frequency  of  recurrence  has  been  disheartening.  Such  patients 
are  difficult  to  trace,  and  I  only  know  of  two  now  alive  and  well  who 
were  operated  on  for  cervix  carcinoma  Ijefore  the  autumn  of  1890. 

Rfxurrence  after  Operation.  —  Under  the  head  of  the  course  and 
symptoms  of  cancer  of  the  vaginal  jjortion  and  cervix,  we  may  best  con- 
sider the  modes  of  recurrence  after  operation.  In  by  far  the  greater 
number  of  operation  cases  it  is  the  cervix,  or  part  of  it,  which  is  affected ; 
and  it  is  after  operation  for  the  malignant  disease  of  the  cervix  that 
recurrence  takes  jjlac^e  in  the  vast  majority  of  cases. 

For  our  present  exact  information  on  this  sidiject  we  owe  much  to 
Winter  (57),  who  carefully  observed  59  cases  of  recurrtuice,  and  jmblished 
the  results  obtained.     He  divided  the  cases  observed  into  three  classes : 


MALIGNANT  DISEASES    OF   THE    UTERUS  697 

(a)  Recurrence  by  metastasis  ;  (b)  Lymiihatic  recurrence  ;  and  (c)  Local 
recurrence  ;  that  is,  at  the  site  of  the  wound. 

With  regard  to  metastasis,  all  observers  are  agreed  that  it  is  not 
common  as  a  result  of  uterine  cancer.  Gusserow  summarised  the 
opinions  which  prevailed  before  total  extirpation  of  the  uterus.  Metas- 
tases, according  to  Blaa  and  others,  occurred  in  the  liver  in  9  per  cent, 
in  the  lungs  in  7  per  cent,  and  in  the  kidneys  in  3-5  per  cent  of  the  cases 
which  ran  their  course.  In  women  who  have  undergone  the  operation  of 
total  extirpation  metastases  are  almost  unknown.  In  43  cases  of  recur- 
rence after  operation,  in  which  he  made  a  post-mortem  examination, 
Winter  did  not  find  a  single  case  with  metastasis.  In  202  cases  of 
recurrence  only  9  were  real  examples  of  metastasis.  Only  2-5  per  cent 
of  all  Avomen  operated  upon  suffered  from  metastases,  which  occurred 
in  the  stomach,  lungs,  liver,  and  ovaries. 

Lymphatic  recurrence  is  of  more  importance.  From  the  cancer  of 
the  cervix  the  glands  which  become  affected  are  the  iliae ;  these  lie  close 
to  the  sacro-iliac  synchondrosis,  just  below  the  brim  of  the  true  pelvis, 
and  at  the  point  of  division  of  the  iliac  and  hypogastric  arteries.  From 
cancer  of  the  body  the  lumbar  glands  are  affected.  These  may  develop 
into  masses  in  which  the  aorta  is  embedded,  and  they  may  be  felt  high 
up  in  the  abdomen.  Occasionally  by  anastomosis  the  obturator  and  in- 
guinal glands  become  affected.  Infection  of  the  pelvic  glands  is  not  so 
common  as  we  might  expect ;  and  it  occurs  comparatively  late.  Blau 
and  Dybowsky,  on  post-mortem  examination  in  203  cases,  found  infection 
of  the  glands  only  40  times.  Winter,  in  the  post-mortem  examinations 
of  43  women,  who  had  undergone  the  total  extirpation  operation,  found 
the  glands  involved  only  three  times,  and  in  only  one  case  Avas  the  cancer 
confined  to  the  uterus.  In  operable  cases  in  clinical  examination  he 
found  the  glands  infected  three  times  ;  when  the  parametrium  was 
involved  the  glands  were  found  to  be  infected  in  24  per  cent  of  the 
cases.  Pure  lymphatic  recurrence  is  rare ;  it  is  in  conjimction  with 
recurrence  in  the  cicatrix  that  the  glands  are  found  most  frequently 
affected. 

Local  recurrence  is  by  far  the  most  frequent  form.  It  occurs  in 
the  cicatrix,  in  the  bladder,  peritoneum,  pelvic  cellular  tissue,  and 
vagina.  The  most  common  cause  of  this  relapse  is  without  doubt  the 
incomplete  removal  of  the  affected  tissue  at  the  operation.  This  recur- 
rence is  then  very  early,  as  a  rule.  All  observers  agree  that  one  chief 
cause  of  recurrence  is  permitting  cancerous  material  to  come  in  contact 
with  the  peritoneum  or  freshly  wounded  tissues.  The  disease  is  then  an 
inoculation  recurrence  ;  and  this  infection  appears  to  take  place  only  on 
account  of  that  special  state  of  health  of  the  patient,  which  made  the 
original  disease  possible.  The  recurrence  in  the  vagina  has  some  points  of 
interest  of  its  own ;  it  must  be  a  fresh  de^^elopment  of  the  disease  produced 
by  prolonged  contact  of  the  cancerous  growth  Avith  a  surface  not  specially 
susceptible.  The  first  time  I  saAv  this  was  in  a  patient  who  underwent 
the  total  extirpation  operation  on  account  of  cancer  of  the  cervix  Avhich 


SYSTEM  OF  GYNECOLOGY 


had.  gro-^-n  into  a  mushroom  mass,  lying  in  contact  with,  the  posterior 
vaginal  wall.  At  the  operation  it  was  found  that  there  was  considerable 
vaginitis  high  up,  and  there  was  one  spot  in  particular  on  the  posterior 
wall  with  broken  down  epithelium.  It  was  red  and  moist  and  sore-looking, 
but  it  was  distinctly  separated  from  the  vaginal  portion  by  a  space  of 
comparatively  healthy  tissue.  Taking  it  for  a  vaginitis  produced  by  the 
discharge,  I  did  not  entirely  remove  this  affected  portion  of  vagina,  and 
was  disappointed  a  few  months  later  to  find  a  new  growth  of  epithelioma 
developing  from  the  area  which  had  apparently  been  the  seat  of  an 
inflammatory  affection  only. 

Many  such  cases  have  been  reported,  and  they  go  to  prove  the  in- 
fectiousness of  cancer  by  prolonged  contact  in  suitable  subjects. 

The  study  of  recurrence  leads  at  every  point  to  important  practical 
conclusions,  especially  with  regard  to  the  need  for  extreme  care  to  pre- 
vent infection  at  the  time  of  operation. 

Sacral  Metliod.  —  The  sacral  method  of  operating  with  which  the 
names  of  Kraske,  Zuckerkandl,  Hochenegg,  and  others  are  associated, 
has  been  practised  a  good  deal  in  Germany,  but  has  received  little  atten- 
tion in  this  country.  The  advantages  originally  claimed  for  it  were  the 
facility  with  which  the  field  of  operation  could  be  reached  and  kept  fully 
in  view,  and  the  widening  of  the  scope  of  the  total  extirpation  by 
sweeping  away  the  affected  parts  more  thoroughly  than  was  practicable 
by  the  vagina.  It  is  also  said  to  be  more  suitable  in  cases  of  cancer 
of  the  body  with  enlargement  of  the  uterus  and  senile  narrowness  of 
the  vagina.     With  this  indication  Fritsch  agrees. 

An  obvious  disadvantage  is  that  it  involves  resection  of  part  of  the 
sacrum  and  consequently  a  prolonged  convalescence.  In  some  of  the 
cases  first  reported  the  sacrum  not  only  did  not  again  unite,  but  even 
necrosed,  with  corresponding  sloughing  of  connected  soft  parts.  One 
such  misadventure  occurred  to  so  experienced  an  operator  as  Hegar. 

Many  proposals  were  consequently  made  for  improving  the  operation, 
and  perhaps  as  noticeable  a  modification  as  any  was  that  proposed  by 
Herzfeld  (IS).  It  is  necessary,  according  to  him,  to  resect  the  coccyx 
only,  or  at  most  al)0ut  one  centimetre  of  the  lowest  part  of  the  sacrum  in 
addition.  An  incision  is  made  along  the  medium  crest  of  the  sacrum,  and 
carried  in  a  slight  curve  to  the  periphery  of  the  anus  on  the  right  side. 
The  recto-vaginal  septum  is  then  easily  found,  and  the  deeper  parts  are 
separated  with  the  finger  tip  or  handle  of  the  scalpel.  The  prevertebral 
fascia  is  thus  brought  into  view,  and  is  cut  through  along  the  right  margin 
of  the  rectum.  Herzfeld  claims  for  this  detail  in  the  operation  that  the 
rectum  does  not  come  in  the  way,  and  it  is  more  easy  to  reach  the  pos- 
terior surface  of  the  vagina  which  can  be  drawn  to  the  right.  The  vagina 
is  easily  distinguished  by  its  whiter  appearance.  Between  the  riglit 
margin  of  the  rectum  and  the  point  of  the  posterior  vaginal  wall  the 
lowest  portion  of  Douglas'  space  is  sure  to  be  found.  Some  recent 
critics  of  the  operation  say  that  they  have  met  with  considerable  diffi- 
culty here. 


MALIGNANT  DISEASES   OF  THE    UTERUS  699 

Herzfeld  takes  the  plica  transversalis  recti  as  a  landmark,  and  can 
with  confidence  open  Douglas'  space  on  the  right  margin  of  the  rectum 
at  this  point.  The  wound  is  cautiously  extended,  and  then  the  uterus 
with  its  adnexa  can  be  drawn  through  in  such  a  way  that  its  anterior 
surface  now  looks  upwards  and  backwards.  On  this  surface  the  line  of 
reflection  of  the  vesico-uterine  fold  of  peritoneum  can  be  distinctly  seen. 
This  portion  of  peritoneum  is  cut  through,  and  the  uterus  is  then  sepa- 
rated from  the  bladder  down  to  the  anterior  insertion  of  the  vagina.  The 
left  broad  ligament  is  now  dragged  upon,  ligatured  and  cut,  and  after  this 
the  peritoneal  opening  is  completely  closed  with  sutures  which  bring 
together  the  posterior  margin  of  the  peritoneum  in  Douglas'  space,  and 
the  cut  margin  of  the  vesico-uterine  fold.  The  rest  of  the  operation, 
which  involves  manipulation  of  the  cancer,  is  entirely  extraperitoneal. 
It  is  claimed  as  an  advantage  for  this  proceeding,  that  it  prevents 
infection  of  the  peritoneum  by  cancer  juice  or  cancer  elements,  and 
thus  helps  to  prevent  the  recurrence  of  the  disease. 

The  broad  ligaments  are  now  tied  in  sections  and  cut  downwards  to 
the  portio  vaginalis.  It  is  said  that  during  these  proceedings  the  vessels 
and  ureters  can  be  distinctly  seen  and  properly  dealt  with.  The  posterior 
wall  of  the  vagina  is  finally  cut  through  and,  when  the  incision  has  been 
carried  round,  the  uteriis  can  be  removed.  It  is  claimed  for  the  opera- 
tion that  the  ligatures  can  be  placed  upon  the  broad  ligaments  as  far 
outwards  from  the  uterus  as  may  be  necessary,  and  the  vagina,  if  affected, 
can  easily  be  resected  to  any  required  extent. 

The  upper  opening  of  the  vagina  may  now  be  closed  Avith  sutures, 
and  drainage  effected  through  the  original  wound  made  in  gaining  access 
to  the  field  of  operation  ;  or  the  wound  may  be  closed  and  the  vagina  be 
left  open  for  drainage.  The  latter  course  was  suggested  by  Schauta, 
and  ai)pears  to  be  preferable. 

The  author  of  this  superior  modification  of  the  sacral  method  admits 
that  it  does  not  extend  the  scope  of  the  operation,  inasmuch  as  when  the 
parametrium  is  involved  it  gives  no  better  results  than  any  other  method 
of  surgical  treatment.  What  is  said  of  it  by  the  most  reasonable  and 
most  highly  qualified  of  critics  may  be  best  stated  in  a  summary  of  Von 
Winckel's  remarks  on  the  subject.  He  had  done  the  operation  in  a  suit- 
able case,  and  in  doing  so  had  observed  some  points  whii-h  he  had  not 
previously  heard  anything  about.  He  had  to  dissect  higher  up  than  he 
had  been  led  to  expect.  When  the  fascia  was  cut  through  air  rushed  in 
and  pushed  all  the  parts  to  the  left ;  this  caused  considerable  delay,  and 
consequently  more  loss  of  blood  than  is  usual  in  the  vaginal  operation. 
The  separation  of  the  left  side  of  the  uterus  and  its  ligation  was  extremely 
difficult.  As  to  the  ureters,  he  could  not  find  them  at  all,  although  he 
searched  for  them  ;  and  he  is  sure  that  in  this  operation  they  are  not 
more  easily  avoided  than  in  the  vaginal  operation.  The  result  of  the 
operation  was  unsatisfactory :  the  vagina  became  fixed  above,  and  sutures 
were  expelled  through  it ;  a  fistula  formed  in  communication  with  the 
bone,  small  spicules  of  bone  continued  to  be  shed  for  months  afterwards, 


700  SVST£J/  OF  GYN.F.COLOGY 

and  tlie  conyalescence  was  very  slow.  His  conclusion  is  tliat  if  by  so 
radical  an  operation  we  can  obtain  no  better  result  than  by  means  of 
the  curette  or  the  cautery,  we  are  bound  to  tell  the  patient  frankly  that 
we  can  promise  nothing  better,  and  to  let  total  extirpation  alone. 

Kecent  reports  suggest  that  some  Continental  gynaBcologists  have 
taken  this  advice  to  heart. 

FreinuVs  Operation. — After  the  first  dubious  successes  of  Langen- 
beck,  Bluadell,  and  Recamier,  in  vaginal  hysterectomy  for  cancer,  early 
in  the  present  century,  all  radical  operations  were  given  up  for  about 
forty  years.  In  1878  Freund,  of  Strassburg,  performed  the  first  suc- 
cessful operation  with  which  his  name  is  associated.  It  consisted  of  a 
vaginal  and  an  abdominal  operation ;  and  in  spite  of  the  tedious  details 
which  it  involved,  and  its  technical  difficulties,  it  Avas  performed  by 
many  gynaecologists  in  Germany  and  elsewhere  in  Europe,  and  by  a  few 
in  England.  The  eagerness  with  which  it  was  adopted  is  in  some  degree 
a  sign  of  the  conscious  helplessness  of  surgery  in  dealing  with  uterine 
cancer  at  that  time. 

It  was  soon  discovered  to  be  a  very  fatal  operation,  and  many  modifi- 
cations were  soon  introduced  in  the  hope  of  diminishing  the  mortality, 
but  with  only  slight  success.  The  dangers  consisted  chiefly  in  the  shock 
from  long  exposure  and  manipulation  of  the  bowels,  obstruction  from 
paralysis  of  the  intestines,  haemorrhage,  infection  from  the  cancerous 
elements,  peritonitis,  and  injuries  to  the  ureters  and  bladder.  Modifica- 
tions were  carried  to  the  extent  of  dividing  the  recti  muscles,  and  even 
of  resecting  the  anterior  pelvic  wall.  The  danger  is  indicated  by  the 
statistics  of  the  early  period  of  the  operation  collected  by  C.  von  Rokit- 
ansky.  Of  ninety-five  women  operated  upon,  sixty-five  died  directly 
from  the  effects  of  the  operation  ;  and  in  all  the  remaining  cases  the 
disease  soon  recurred. 

It  may  be  said  that  the  operation  has  been  abandoned  except  to  meet 
a  certain  comparatively  rare  combination  of  circumstances,  as  in  cancer 
with  myoma  or  in  large  sarcoma  of  the  uterus.  There  is,  perhaps,  quite 
recently  a  disposition  to  give  the  operation  more  attention,  since  such 
satisfactory  results  have  been  obtained  in  the  similar  operation  for 
fibromyoma  of  the  uterus. 

H.  W.  Freund  (9),  who  may  naturally  be  disposed  to  tliink  well  of 
the  operation,  recently  gave  the  results  up  to  date  (from  188G)  as  show- 
ing a  mortality  of  33  per  cent  in  twenty-seven  cases.  Up  to  188G  the 
mortality  for  all  the  cases  collected  was  67  per  cent.  In  ten  recent 
cases  at  the  Strassburg  Hospital  there  were  two  deaths  from  the  opera- 
tion, and  two  more  witliin  a  f(;vv  weeks. 

The  teclijiifiue  of  tlie  operation,  with  all  improvements  as  now  per- 
formed at  StrassVjurg,  is  shortly  as  follows  :  The  patient  is  i)ut  on  the 
table,  and  the  X)elvis  raised  into  the  high  position  (Beckenhochlagerung) 
by  means  of  a  suitable  pad  placed  under  the  hips.  The  vaginal  wall  is 
incised  round  the  portio  vaginalis;  Douglas'  space  is  opened  as  com- 
pletely as  possible,  and  a  sponge  is  pushed  through  the  opening.     A 


MALIGNA  NT  DISEASES    OF  THE    UTERUS  701 

suitable  hydrostatic  dilator  or  bag  is  introduced  into  the  vagina  and 
made  as  tense  as  possible;  by  this  means  the  uterus  is  raised  out  of  the 
pelvis,  and  thus  the  abdominal  part  of  the  operation  is  much  facilitated. 
When  the  abdominal  cavity  has  been  opened  by  a  full  incision  the  pro- 
cess of  separating  the  bladder  from  the  uterus  is  at  once  begun,  and  is 
easily  completed  with  the  guidance  of  a  sound.  The  old  practices  of 
drawing  out  the  intestines  and  distending  the  bladder  have  been  given 
up.  The  appendages  and  the  broad  ligaments  are  tied  in  sections  and 
cut  through  on  each  side  as  in  the  ordinary  operation;  and  owing  to 
recent  modifications  this  part  of  the  operation  is  remarkably  easy.  The 
ligatures  of  the  broad  ligament,  which  are  left  long,  are  now  drawn  down 
through  the  vagina ;  and  the  anterior  and  posterior  cut  margins  of  the 
peritoneum  are  brought  together  with  sutures.  The  peritoneal  cavit}' 
may  be  completely  shut  off  from  the  vagina,  or  a  sufficient  opening  left 
for  drainage. 

Partial  Extirpation.  —  The  operation  which  is  the  rival  or  alternative 
to  total  extirpation  is  not  any  one  of  the  modifications  mentioned,  but 
partial  extirpation,  or  high  amputation  of  the  uterus.  This  operation  was 
the  first  great  step  in  advance,  in  the  surgical  treatment  of  uterine  cancer, 
beyond  the  futile  and  sometimes  injurious  measures  formerly  in  vogue, 
such  as  the  ap})lication  of  caustics  or  escharotics,  and  the  use  of  the  chain 
ecraseur  or  the  galvanic  ecraseur.  There  can  be  no  doubt  that  excellent 
results  were  obtained  by  the  partial  extirpation  of  the  uterus,  and  some 
able,  experienced,  and  conscientious  gynaecologists  still  maintain  that  it 
is  the  best  operation,  and  endeavour  to  restrict  total  extirpation  within 
the  narrowest  possible  limits.  Biit  even  its  strongest  advocates  have  to 
admit  that  it  is  losing  ground.  One  of  these  (58)  begins  his  advocacy  of 
the  partial  operation  as  follows:  —  ''The  total  extirpation  of  the  uterus 
per  vaginam  has  become  more  and  more  the  favourite  operation  of  the 
German  gynaecologists.  The  safe  and  even  elegant  technique,  the  brill- 
iant results,  and  the  permanent  success  are  constantly  adding  to  the 
number  of  those  who  speak  well  of  it.  The  foreign  gynaecologists  gradu- 
ally follow  the  lead  of  Germany,  so  that  now  scarcely  an  opponent  of 
the  operation  may  be  said  to  exist.  Schroeder's  operation  of  amputation 
of  the  cervix  for  cancer  of  the  portio  vaginalis  has  become  so  completely 
obsolete  that  it  is  scarcely  ever  referred  to  in  works  on  total  extirpation, 
much  less  brought  into  comparison  Avith  it." 

The  introduction  of  the  operation  of  partial  extirpation  of  the  uterus 
is  usually  attributed  to  Schroeder,  who  continued  to  practise  it  after  most 
of  his  contemporaries  had  declared  for  total  extirpation.  The  practice 
and  advocacy  of  the  operation  appear  to  have  been  carried  on  mainly  by 
Hofmeier,  AVinter,  and  other  pupils.  In  this  country  Sir  John  Williams 
has  been  the  chief  advocate  of  partial  extirpation ;  in  fact,  the  portion 
of  his  work  Avhich  he  devotes  to  the  surgical  treatment  of  cancer  of 
the  uterus  is  largely  an  effort  to  i)rove  that,  in  cancer  of  the  portio 
vaginalis  and  of  the  cervix,  total  extirpation  of  the  uterus  possesses  no 
advantages  over  supravaginal  amputation  of  the  cervix.     He  endeavours 


702  SYSTEM   OF   GYNECOLOGY 

to  establish  his  proof  by  evidence  from  pathology  and  from  clinical 
experience. 

The  argument  from  pathology  depends  almost  entirely  upon  the 
belief  that  cancer  of  the  cervix  begins  in  certain  situations,  and  has  a 
tendency  to  grow  downwards  or  outwards  towards  the  parametric  con- 
nective tissue.  This  is  not  the  place  to  go  into  controversial  details, 
but  it  ma}'  be  stated  with  confidence  that  more  recent  observations  lead 
to  the  conclusion  that  the  views  stated  are  not  consonant  with  the 
facts,  and  therefore  the  argument  for  partial  amputation,  so  far  as  it 
depends  upon  the  facts,  entirely  fails. 

With  regard  to  what  may  be  called  the  clinical  argument,  Sir  John 
Williams  asks :  What  does  the  experience  of  operators  tell  us  on  the 
subject  ?  A  good  deal  has  happened  since  Cancer  of  the  Uterus  was  pub- 
lished in  1888,  and  the  views  of  some  experienced  operators  may  be  in- 
ferred from  the  language  used  by  Winter  three  years  later.  At  a  time 
when  total  extirpation  was  looked  upon  as  a  formidable  and  dangerous 
operation  it  was  natural  enough  to  endeavour  to  make  the  most  of  the 
partial  operation ;  but  it  has  been  proved  by  the  results  of  operators 
within  the  last  few  years,  that  total  extirpation  is  not  necessarily  a  more 
dangerous  operation  than  supravaginal  amputation.  On  the  relative  fre- 
quency of  recurrence  after  the  two  operations,  and  the  comparative  length 
of  time  of  immunity,  no  satisfactory  conclusion  can  be  drawn  from  such 
arguments.  It  is  almost  invariably  a  comparison  of  unlike  things,  because 
the  operation  of  partial  extirpation  was  reserved  for  the  most  favourable 
cases ;  it  was  only  when  the  disease  was  more  advanced  that  total  extir- 
pation was  attempted  by  the  early  operators.  Considering  the  improve- 
ment in  the  technique  of  the  operation,  and  the  encouraging  results  of 
the  most  experienced  operators,  who  deal  with  all  cases  by  total  extir- 
pation, the  advantages  appear  now  to  be  almost  entirely  on  the  side  of 
total  extirpation. 

The  object  of  the  partial  operation  is  to  operate  within  healthy  tissue 
in  the  parametrium,  and  to  reach  up  as  high  as  possible  without  opening 
the  peritoneum.  It  is  claimed  for  the  operation  that  it  is  comparatively 
easy  of  performance ;  that  there  is  little  shock ;  that  the  field  of  opera- 
tion is  entirely  within  the  operator's  view  and  control,  and  that  ileus 
and  peritonitis  are  avoided.  One  advocate,  at  least,  of  the  supravaginal 
amputation  seriously  states,  as  a  point  in  favour  of  partial  operation, 
that  a  woman  may  become  pregnant  and  even  go  to  full  term  after  having 
the  cervix  uteri  removed  for  cancer,  and  he  produces  several  cases  from 
the  literature  of  the  subject.  He  is  able  to  show  also,  altliough  our  at- 
tention is  not  specially  drawn  to  the  fact,  that  some  of  these  women  who 
became  pregnant  soon  lost  their  lives  from  recurrence  and  rajjid  growth 
of  the  disease.  WoiiKiu  before  the  menopause  are  liable  after  high  ampu- 
tation to  cicatricial  contraction  of  the  lumen  of  the  uterine  canal,  and 
to  constant  sufferings  dependent  upon  that  fact.  The  avoidance  of  so 
grave  a  result  of  the  operation  is  in  itself  a  very  strong  ground  for  pro- 
ceeding to  total  extirpation.     In  favour  also  of  total  extiri)ation  is  the 


MALIGNANT  DISEASES   OF   THE    UTERUS  703 

fact  that  we  can  never  be  certain  of  the  extent  of  the  diseased  tissues. 
Many  cases  are  reported  in  the  literature  of  the  subject,  and  I  have 
myself  seen  several,  in  which  there  were  distinct  centres  of  develop- 
ment of  the  malignant  disease;  and  consequently  partial  extirpation 
would  have  been  a  useless  operation.  Then  again,  in  the  partial  opera- 
tion there  is  a  much  larger,  and  a  less  completely  finished  wound  than 
in  the  complete  operation ;  so  that,  with  an  extensive  surface  which 
should  granulate,  there  is  probably  more  danger  of  parametritis  and 
diffusion  of  the  cancer  than  there  is  when  the  broad  ligaments  are 
efficiently  ligated,  and  both  blood-vessels  and  lymphatic  channels  are 
almost  completely  cut  off. 

After  all  operations  for  cancer  of  the  uterus,  the  recurrence  takes 
place  most  frequently  in  the  site  of  the  wound,  and  in  women  who  are 
still  menstruating  it  stands  to  reason  that  recurrence  is  less  likely  to 
take  place  when  quiescence  of  the  parts  is  brought  about  by  the  com- 
plete operation.  The  ebb  "and  flow  of  menstruation,  and  the  influence 
of  blood-supply  on  the  nervous  system  of  the  parts  by  emotional  condi- 
tions in  the  ante-cliraacteric  age,  are  much  more  likely  to  bring  about 
recurrence  than  when,  by  complete  removal  of  the  uterus,  and  perhaps 
of  the  ovaries  as  well,  the  menopause  is  prematurely  brought  on. 

It  seems  to  me  that  there  is  only  one  clearly  definite  class  of  case 
of  cancer  of  the  portio  vaginalis  in  which  partial  operation  may  be  the 
best  operation ;  that  is  in  elderly  or  old  women,  in  whom  the  disease  is 
very  slowly  developing,  and  in  whom  the  uterus  is  perfectly  movable, 
and  the  vagina  narrow  and  senile. 

With  regard  to  the  technique  of  the  operation  it  is  hardly  neces- 
sary to  go  into  details.  It  is  really  almost  invariably  identical  with 
the  first  stages  of  the  complete  operation.  One  point  in  the  operation, 
which  should  be  considered  essential,  is  the  timely  shutting  off  of  the 
blood-supply  by  the  uterine  arteries ;  after  that  is  done  the  separation 
of  the  cervix  from  its  surrounding  structures  and  its  amputation  are 
comparatively  easy  proceedings,  unembarrassed  by  any  considerable 
amount  of  haemorrhage. 

Palliative  Operations.  —  When  the  cancer  is  too  far  advanced  for 
any  radical  operation  the  question  always  arises  whether  any  benefit 
at  all  can  be  conferred  by  local  treatment.  The  patient  has  reached  the 
stage  at  which  symptoms  have  to  be  treated  as  tliey  appear ;  but  such 
treatment  is  dreary  and  unsatisfactory  work,  and  every  available  means 
should  be  brought  into  use  which  offer  any  reasonable  ground  for  the 
expectation  of  benefit.  In  a  considerable  proportion  of  the  advanced 
cases  there  is  a  deep  ulcerating  cavity  which  may  contain  spongy  debris, 
the  result  of  the  necrosis  of  the  uterine  tissues.  In  such  cases  there  is 
a  foul  and  copious  discharge  with  intermittent  attacks  of  haemorrhage. 
These  are  the  cases  in  which  the  sapraunic  process  at  work  is  also  doing 
the  most  harm  in  sapping  the  patient's  strength.  What  means  of  local 
treatment  worth  employing  have  we  at  our  disposal  ? 

1.   The  sharp  curette  is  naturally  placed  first;  whether  it  be  used 


704  SYSTEM  OF  GYNECOLOGY 

alone  or  supplemented  by  some  chemical  agent  to  destroy  the  infected 
tissues  further. 

In  such  patients  we  cannot  use  the  curette  efficiently  without  the  aid 
of  an  anaesthetic.  Yet  when  there  are  grave  objections  to  the  administra- 
tion of  chloroform  or  ether,  the  operation  may  still  be  carried  out  more 
or  less  completely  without  inflicting  much  pain.  In  such  cases  I  have 
found  it  of  great  advantage,  about  an  hour  before  the  time  appointed  for 
operating,  to  give  a  considerable  hypodermic  injection  of  morphia;  and 
just  a  few  minutes  before  beginning  a  fair  dose  of  whisky  or  brandy  well 
diluted.  When  these  medicines  have  taken  effect  it  is  wonderful  how  well 
the  patient  can  bear  even  a  tolerably  thorough  use  of  the  instrument. 

In  an  ordinary  case,  when  the  patient  has  been  put  under  the 
anaesthetic,  it  is  best  to  place  her  on  a  table  in  a  good  light,  and 
proceed  with  all  the  care  as  to  detail  and  all  the  circumstance  of  an 
important  operation.  The  reason  why  so  many  private  patients  are 
treated  so  inefficiently  as  compared  with  our  hospital  cases  is  largely, 
I  believe,  because  Ave  give  too  much  heed  to  paltry  objections  to  ex- 
posure, to  the  use  of  an  operating  table,  and  so  forth.  The  patient  is 
placed  in  the  lithotomy  position,  and  the  parts  are  thoroughly  brought 
into  view  with  the  aid  of  the  weighted  speculum.  The  uterus  and 
vagina  are  thoroughly  swabbed  with  a  solution  of  mercury  which  helps 
to  deodorise  as  well,  and  the  uterus  is,  if  necessary,  steadied  with  a 
volsella.  The  broken  down  tissue  is  then  rapidly  swept  away,  and 
every  portion  of  the  cavity  is  carefully  gone  over  in  detail  until  the 
instrument  is  felt  to  rasp  upon  firm  tissue.  It  is  occasionally  neces- 
sary to  cut  away  tags  of  comparatively  healthy  material,  chiefly  at  the 
margins  of  the  ulcer.  The  cavity  is  frequently  swabbed  Avith  cotton 
wool  soaked  in  mercury  solution,  and  is  finally  packed  with  gauze  or 
lint  wrung  out  of  the  same  solution. 

Such  an  operation  has  its  uses  in  stopping  haemorrhage  and  foul 
discharge  for  a  time,  but  only  comparatively  slight  and  evanescent 
effects  are  to  be  expected  from  it. 

If  the  curette  be  worth  using,  its  action  should  be  supplemented  by 
an  escharotic ;  and  of  all  the  substances  available  at  present  there  can 
1)6  little  question  that  zinc  chloride  is  the  best.  It  should  be  put  ready 
beforehand  to  apply  immediately  after  the  curetting,  and  it  should  be 
in  the  strongest  manageable  form.  A  solution  of  one  in  two  or  three, 
or  a  paste  of  equal  parts  of  the  chemical  and  moist  flour,  answers  very 
well.  It  may  be  applied  advantageously  on  the  end  of  a  shred  of  lint 
like  a  narrow  bandage,  the  dry  portion  being  packed  in  after,  so  as  to 
keep  the  active  agent  in  its  place.  Every  care  should  be  taken,  by 
j)ledgets  of  cotton  wool  or  lint  soaked  in  a  strong  solution  of  soda 
bicarVjonate,  to  protect  the  vagina  from  any  surplus  zinc  salt.  It  is  a 
good  plan  to  finish  l)y  ])acking  the  vagina  with  a  taiii]Km  consisting  of 
a  long  strip  of  lint  soaked  in  a  strong  solution  of  soda,  ''i'his  tampon 
may  be  left  for  a  day  or  even  for  two  days ;  it  is  then  removed  and  an 
antiseptic  douche  copiously  used. 


MALIGNANT  DISEASES   OE   THE    UTERUS 


There  are  many  other  methods  of  employing  this  treatment,  but 
there  is  no  difference  in  essential  details.  From  very  considerable 
experience  I  can  speak  well  of  the  method  here  described. 

The  eschar  keeps  coming  away  in  shreds  or  in  liquid  under  the  use 
of  the  douche  for  a  week  or  so.  During  this  time,  and  it  may  be  for 
long  afterwards,  a  marked  change  for  the  better  takes  place  in  the 
patient.  The  saprsemic  temperature  goes  down ;  she  is  comparatively 
free  from  pain ;  the  haemorrhage  ceases ;  the  discharge  is  greatly  modi- 
fied in  many  respects,  and  is  almost  free  from  smell ;  the  cavity  may 
take  on  the  appearance  of  a  healthy  granulating  surface,  covered  with 
a  thin  mattery  discharge.  Later,  the  cavity  gradually  contracts,  cica- 
tricial tissue  forms,  and  the  improvement  may  last  for  many  months. 
Meanwhile  the  patient  becomes  stronger.  She  puts  on  flesh,  and  loses 
in  a  great  measure  the  anaemic  or  cachectic  appearance. 

Some  one  or  other  of  the  above  palliative  operations  may  be  used 
repeatedly  with  advantage  when  haemorrhage  and  foul-smelling  discharge 
show  that  the  ulceration  is  making  progress. 

It  has  been  raised  as  an  objection  to  the  curette  that  there  is  danger 
of  perforating  the  uterus,  and  some  cases  have  been  reported  in  which 
this  "accident"  has  occurred.  But  the  same  kind  of  objection  might 
be  made  to  many  of  our  most  useful  medical  and  surgical  means  of  com- 
bating disease.  Some  drugs  are  powerful  poisons,  and  all  scalpels  should 
be  sharp.  Two  conditions  are  required  for  the  successful  use  of  the 
curette  :  the  case  selected  for  treatment  must  be  suitable,  and  the  instru- 
ment must  be  used  with  reasonable  care  and  skill.  "When  so  employed 
the  curette  is  one  of  the  most  useful  instruments  the  gynaecologist  has 
at  his  command. 

The  curette  does  sometimes  cause  considerable  haemorrhage  which  is 
not  easily  stopped.  It  is  occasionally  necessar}'  to  use  a  very  firm 
tampon  and  even  counterpressure  from  above  the  pubes  before  it  ceases. 
But  as  a  rule  the  amount  of  bleeding  is  verj^  slight,  and  the  oozing  ceases 
at  once  on  the  introduction  of  the  tampon  with  zinc  solution. 

A  more  valid  objection  is  the  fear  of  too  extensive  an  action  of  the 
zinc  chloride  upon  the  tissues.  This  objection  applies  to  nitric  acid, 
and  to  other  less  manageable  and  less  useful  chemicals  which  have  been 
used  for  the  same  purpose.  If  care  be  taken  to  ascertain  the  depth  of 
uterine  tissue  between  the  ulcer  and  tlie  peritoneum,  and  due  allowance 
be  made,  the  danger  is  reduced  to  the  mininium ;  and  tlie  result  may 
fall  little,  if  at  all,  short  of  that  obtained  by  supravaginal  amputation. 

The  chemical  substances  which  are  occasionally  applied,  alone  or 
in  supplement  to  the  curette  —  such  as  lunar  caustic,  iodine  solution, 
bromine,  sul]>hate  of  copper,  solution  of  the  perchloride  of  iron,  and  so 
forth  —  ought  all  to  be  discarded.  They  are  difficult  to  control,  and  are 
consequently  liable  to  cause  injury  to  healthy  parts;  or  they  may  pro- 
duce discoloration  of  the  tissi;es  and  an  ambiguous  state  of  the  infected 
area,  an  ambiguity  as  likely  as  not  to  be  cleared  up  in  the  revelations 
of  an  increased  rate  of  La-o-\\i;h  due  to  the  irritation. 


706  SYSTEM  OF  GYNECOLOGY 

2.  TJie  Cautery.  — The  use  of  the  cautery  is  one  of  the  best  methods 
of  dealing  with  inoperable  cases  of  cancer  of  the  uterus.  It  appears 
to  be  a  special  favourite  in  German  Kliniks  ;  but  it  has  not  hitherto 
received  the  attention  in  this  country  which  perhaps  it  deserves.  One 
of  the  difl&eulties  we  have  to  meet  in  the  efficient  use  of  the  cautery  is 
to  find  a  suitable  instrument.  The  ordinary  cautery,  prepared  to  a  white 
heat  and  then  applied  when  it  is  getting  dull,  is  theoretically  one  of  the 
best ;  but,  unfortunately,  in  practice  it  invariably  gets  cooled  down  too 
rapidly,  and  it  is  necessary  to  wait,  with  the  patient  under  the  anaes- 
thetic, until  the  instrument  is  again  heated ;  or  to  keep  a  series  of  the 
instruments  hot  and  use  them  at  intervals.  The  same  objection  applies 
very  largely  to  Pacquelin's  cautery.  It  is  applied  apparently  in  perfect 
order,  but  it  is  liable  to  be  cooled  down  by  the  blood,  and  time  is  lost 
in  again  reheating  it ;  at  least,  such  is  my  experience  of  the  use  of  the 
cautery  in  this  operation. 

One  of  the  most  effective  forms  of  cautery  is  the  galvanic,  which 
consists  of  a  suitable  stem  for  application,  with  means  for  turning  on 
and  interrupting  the  current ;  the  effective  part  of  it  consists  of  a  porce- 
lain button  surrounded  and  covered  with  platinum  wire  which  is  con- 
nected with  the  battery.  This  cautery  as  a  rule  works  well,  but  I  have 
repeatedly  found  that  if  we  attempt  to  increase  the  strength  of  the  cur- 
rent as  the  button  cools  down,  the  platinum  wire  gives  way  and  the 
operation  suddenly  collapses.  All  the  objections,  also,  which  may  be 
reasonably  brought  against  the  use  of  the  curette  are  yet  more  applicable 
to  the  use  of  the  cautery.  Among  the  chief  advocates  of  this  method  of 
palliative  treatment  we  must  count  Fritsch,  who  trusts  to  it  as  the  means 
of  destroying  the  infiltrated  tissue,  and  of  bringing  about  similar  results 
to  those  obtained  by  the  efficient  use  of  chloride  of  zinc.  He  uses  it  as 
the  special  means  of  producing  a  result ;  not  as  a  supplement  to  the  use 
of  the  curette,  as  is  strongly  recommended  by  many  operators. 

Supposing,  in  any  given  case,  the  endeavour  to  use  Pacquelin's  cautery 
for  the  jjurpose  of  destroying  the  affected  tissue  in  a  case  of  crater-like 
ulcer  of  the  uterus  be  resolved  upon,  the  parts  must  be  exposed  by  means 
of  a  tubular  speculum  which  does  not  readily  convey  heat.  The  tem- 
perature of  the  cautery  has  to  be  kept  up  with  the  aid  of  an  efficient 
assistant ;  and  after  the  comparatively  slight  use  of  the  curette  the  point 
of  the  cautery  button  is  applied  to  all  the  suspected  area.  There  is 
always  a  certain  amount  of  haemorrhage,  and  the  blood  has  not  only  a 
tendency  to  cool  the  instrument,  but  to  obscure  our  view  of  the  field  of 
operation.  Fritsch  trusts  entirely  to  the  cautery  to  produce  the  desired 
result,  and  an  account  of  his  method  of  treatment  may  be  worth  insert- 
ing here :  — 

The  patient  is  placed  in  the  lithotomy  position,  and  the  soft  portions 
of  the  uterine  ulcer  are  removed  l)y  means  f)f  the  sharp  curette  or  a  large 
sharp  spoon.  The  instrument  is  firmly  and  rapidly  used  to  remove  the 
whole  of  the  soft  infiltrated  tissue ;  the  main  reason  for  prompt  and  rapid 
action  being  the  important  amount  of  haimorrhage  which  so  frequently 


MALIGNANT  DISEASES   OF   THE    UTERUS  707 

occurs.  Shreds  of  uterine  tissue  which  evaded  the  curette  must  be  seized 
hold  of  by  forceps  and  cut  away.  The  crater  is  then  thoroughly  burned 
out  by  means  of  the  point  of  the  button  of  the  Pacquelin  cautery.  If  the 
actual  cautery  be  employed,  it  should  be  used  when  it  is  becoming  dull, 
not  at  the  white  heat.  The  burning  by  means  of  the  cautery  should  be 
effected  in  a  thoroughly  energetic  manner,  Avorking  high  up  into  the 
uterine  tissues,  and  transversely  into  the  parametrium.  The  process  is 
continued  until  hceniorrhage  is  completely  stopped,  and  until  the  surface 
of  the  tissues  so  treated,  when  tapped  with  the  cautery  point,  produces 
an  impression  as  if  it  were  tapping  upon  horn  or  cartilage.  If  the 
speculum  show  any  sign  of  becoming  too  hot  it  must  be  cooled  down 
by  means  of  cold  water  compresses.  Where  there  has  been  great  loss 
of  substance  thei-e  appears  to  be  some  danger  of  roasting  tissues  too 
close  to  the  peritoneal  surface  of  the  uterus ;  it  is  better,  then,  to  do 
a  partial  operation  and  repeat  it  in  two  or  three  days.  After  the  burn- 
ing the  cavity  is  packed  with  a  suitable  tampon  consisting  of  dermatol- 
gauze ;  the  cavity  is  also  treated  with  an  astringent. 

There  can  be  little  doubt  that  it  is  a  good  plan,  even  after  such  ener- 
getic use  of  the  cautery,  to  pack  the  crater  with  an  antiseptic  tampon ; 
and  this  tampon  is  best  applied  by  means  of  an  exceptionally  long 
forceps ;  made  very  much  in  the  pattern  of  the  dissecting  instrument. 

After  such  an  operation  the  completely  destroyed  tissues  begin  to  be 
shed,  either  in  the  form  of  considerable  shreds  or  of  a  liquid,  the  result 
of  the  breaking  down  of  the  tissue  internall3^ 

Fritsch  does  not  think  well  of  the  chloride  of  zinc  treatment  which 
he  has  tried  in  all  its  modifications  for  between  twenty  and  thirty  years. 
He  says  it  produces  a  hard  cicatrix  which  becomes  denser  and  harder 
and  is  ultimately  the  seat  of  neuralgic  pain ;  and  all  this  without  stop- 
ping to  any  great  extent  the  progress  of  the  disease. 

He  prefers  to  apply  the  curette  and  remove  the  soft  tissue;  then  to 
cauterise,  and  afterwards  to  continue  to  use  tampons  with  a  mixture  of 
boric  and  tannic  acid. 

Among  the  agents  which  have  been  used  in  powder,  suspension,  or 
solution  to  delay  the  progress  of  the  disease,  to  soothe  it,  and  to  deo- 
dorise it,  may  be  mentioned  alum,  thymol,  boric  acid,  salicylic  acid, 
carbolic  acid,  creolin,  lysol,  and  iodoform.  There  is  something  to  be 
said  for  each  of  them ;  they  are  all  chemical  agents,  possessing  qualities 
which  may  be  of  service  in  inoperable  cancer  of  the  uterus. 

3.  Interstitial  Injections  by  the  Hypodermic  Syringe.  —  Dissatisfaction 
with  the  treatment  by  curette  and  cautery  has  led  to  the  attempt  to 
treat  cancer  by  the  introduction  of  certain  chemical  substances  into  the 
parenchyma  of  the  uterus,  just  beneath  the  infiltrated  parts.  The 
method  has  been  largely  of  the  nature  of  an  experiment,  and  the  results 
published  cannot  be  considered  brilliant. 

Thinking  that,  if  the  bacterial  element  in  a  case  of  ulcerating  cancer 
could  be  removed,  the  rate  of  growth  might  be  diminished  and  some  of 
the  disagreeable  features  in  a  case  might  be  more  or  less  ameliorated, 


7o8  SYSTEM/   OF  GYNECOLOGY 

the  -writer  a  few  years  ago  tried  the  injection  of  small  doses  of  a  solution 
of  perchloride  of  mercur}^  into  the  tissues  of  the  cancerous  uterus ;  it 
would  be  too  sanguine  to  describe  the  results  as  more  than  negative, 
except  indeed  that  a  good  deal  of  pain  was  inflicted.  The  process  has 
been  tried  again  at  our  Cancer  Hospital  without  any  better  results. 

Within  recent  years,  however,  a  considerable  number  of  contribu- 
tions to  this  therapeutic  method  have  appeared  in  the  medical  journals, 
and  it  is  claimed  by  the  authors  that  they  have  met  with  encouraging 
success. 

Bernhardt  treated  six  cases  with  injections  of  salicylic  acid  solution 
(6  per  cent),  and  expresses  himself  satisfied  with  the  results  obtained. 

Schultz  of  Buda-Pesth  appears  to  have  begun  this  treatment  amongst 
the  first.  He  gives  an  account  of  thirty  cases  in  which  he  injected 
alcohol ;  in  his  opinion  with  satisfactory  results.  The  treatment  requires 
much  care  and  time ;  it  is  laborious  for  the  surgeon  and  painful  to  the 
patient. 

Yulliet  also  published  an  account  of  his  method  of  injecting  absolute 
alcohol.  He  reported  four  cases,  and  was  pleased  with  the  result,  con- 
sidering one  of  the  cases  a  brilliant  success.  He  used  a  large  nu.mber 
of  needles,  and  he  made  nine  to  a  dozen  "  prickings,"  injecting  each  time 
three  or  four  drops,  if  he  did  not  meet  with  "a  too  sensitive  subject." 
In  all  the  patients  the  treatment  caused  considerable  pain,  and  in  one 
rather  alarming  general  symptoms.  She  said  she  felt  as  if  quicksilver 
were  circulating  in  her  blood-vessels.  The  best  result  obtained  was  a 
considerable  amount  of  cicatrisation  in  the  neoplasm,  the  area  of  which, 
however,  ultimately  became  neuralgic  and  gave  rise  to  much  pain. 

It  is  claimed  for  the  process  that  it  causes  cicatrisation,  diminishes 
discharge,  and  occasionally  produces  a  perfect  cure ;  on  the  other  hand, 
it  is  admitted  that  each  repetition  of  the  injections  amounts  to  a  pain- 
ful operation ;  that  these  operations  must  be  frequently  repeated,  and 
that  the  result  is  always  uncertain.  Vulliet  considers  the  most  favour- 
able case  the  one  in  which  a  neuralgic  cicatrix  remained. 

Suppression  of  Hcnmorrhage  and  Diminution  of  the  Foul  Discharge.  — 
As  the  disease  advances  these  objects  become  among  the  chief  concerns 
of  the  medical  attendant,  apart  altogether  from  operative  treatment. 
The  one  rajjidly  saps  the  patient's  strength  and  brings  on  anaemia ;  the 
other  poisons  her,  and  makes  her  an  object  of  distress  or  disgust  to 
herself  and  to  those  about  her. 

Owing  to  the  irritable  condition  of  the  patient's  digestive  organs  and 
lower  alimentary  canal,  it  is  necessary  to  make  the  most  of  local  meas- 
ures. One  great  difficulty  in  the  treatment  is  the  anorexia;  and  we 
cannot  afford  to  upset  such  digestion  as  there  may  be  by  styptic  and 
antiseptic  remedies  —  such  as  mineral  acids,  tannin,  crgotin,  or  any  of 
the  turpetine  series  —  administered  by  the  mouth. 

For  the  arrest  of  ha^jmorrliage  we  must  trust  to  ])ressuro  by  a 
tampon  introduced  into  the  vagina,  and  ])lanted  firmly  upon  tlie  bleed- 
ing ulcer-surface.     It  is  usual  to  supplement  the  haemostatic  effects  of 


MALIGNANT  DISEASES    OF  THE    UTERUS  709 

the  pressure  by  means  of  a  styptic.  The  great  objection  to  the  use  of 
the  salts  of  iron  for  this  purpose  is  the  embarrassing  discoloration  pro- 
duced by  them.  Each  of  the  other  known  styptics  has  had  its  advocates. 
An  endeavour  has  usually  been  made  to  find  an  agent  with  deo- 
dorising proxjerties  in  addition  to  the  haemostatic.  The  objection  to 
terebene  and  turpentine,  combined  with  oils  or  in  any  other  way,  is 
that  they  produce  a  certain  amount  of  pain  internally  and  irritation 
about  the  external  genitals.  A  Aveak  solution  of  chloride  of  zinc,  with 
or  without  the  addition  of  iodoform,  makes  a  useful  material  for  appli- 
cation ;  and,  among  those  which  I  have  tried,  I  know  nothing  better 
than  a  solution  of  acetate  of  lead  in  glycerine,  with  a  small  proportion 
of  carbolic  acid  and  morphia  added. 

When  the  disease  is  far  advanced  beyond  the  stage  of  active  haemor- 
rhage, it  is  the  foul  discharge  and  the  pain  which  we  have  chiefly  to 
consider  in  our  treatment.  The  discharge,  moreover,  frequently,  pro- 
duces vulvitis,  and  dermatitis,  inside  the  thighs  and  in  the  groins.  We 
must  trust  largely  to  internal  sedatives  to  relieve  the  distress,  but  the 
smell  and  irritating  character  of  the  discharge  may  be  modified  by  local 
means  —  chiefly  by  the  use  of  the  syringe  charged  Avith  a  solution  of 
mercury  or  carbolic  acid.  An  alkaline  solution  may  be  occasionally 
advantageous  for  cleansing  and  soothing,  but  the  great  majority  of  the 
chemical  substances  used  in  solution  appear  to  serve  no  useful  purpose 
whatever.  Copious  use  of  warm  water,  or  weak  salt  and  water,  is  quite 
as  useful.  The  whole  object  of  this  phase  of  the  treatment  is  to  kesp 
the  affected  parts  as  little  septic  as  possible,  and  to  prevent  discomfort. 

AVhen  the  stage  of  the  disease  is  reached  at  which  pain  becomes  a 
symptom,  it  is  necessary  to  begin  the  administration  of  sedative  drugs ; 
and  this  part  of  the  treatment  may  be  almost  entirely  summed  up  in 
the  administration  of  morphia  in  some  convenient  form ;  no  other 
drug  is  to  be  compared  with  it  in  its  beneficial  effects.  Its  action  may 
have  to  be  supplemented  in  some  cases  by  sedatives  which  have  more 
of  a  soporific  action,  but  it  may  be  said  with  entire  confidence  that 
there  is  no  substitute  for  it.  In  inoperable  cases  of  cancer  there  can 
be  no  reasonable  ground  for  hesitating  to  give  whatsoever  doses  may 
be  necessary  to  afford  relief  from  suffering.  In  some  comparativelj* 
rare  complications,  such  as  pyometra  and  heematometra  or  concurrent 
disease  of  the  Fallopian  tubes  producing  spasm,  considerable  temporary 
relief  may  be  given  by  the  administration  of  antipyrin,  or  the  extract 
of  viburnum ;  but  the  depressing  by-effects  of  these  drugs  must  be 
kept  constantly  in  mind.  In  the  distress  about  the  anus  and  vulva, 
from  pressure  in  the  comparatively  late  stages,  the  action  of  the  morphia 
may  be  usefully  supplemented  by  the  use  of  an  ointment  of  lanolin 
containing  cocaine,  morphia,  and  tannin.  When  symptoms  of  renal 
complications  conu^  on  it  is  still  necessary  to  continue  the  use  of  mor- 
phia, while  other  measures  are  taken  on  the  general  principle  of  giving 
relief  in  kidney  disease.  It  is  not  as  a  rule  possible,  even  if  it  were 
advisable,  to  put  the  patient  on  any  regimen  dictated  by  some  supposed 


7IO  SYSTEM  OF  GYX.-ECOLOGY 

advantages  in  the  method  of  diet.  The  dietary  should  be  as  generous 
and  varied  as  possible  ;  the  main  difficulty  in  dealing"  with  the  patient 
is  not  to  select  the  food,  but  to  get  her  to  take  any.  The  object  to  be 
kept  in  view  is  obviously  to  assist  and  maintain  the  nutrition  as  long  as 
possible,  and  prevent  the  inroads  made  upon  the  strength  by  htemorrhage, 
septicaemia,  and  pain.  With  this  object  the  usually  recognised  adjuvants 
to  digestion,  such  as  pepsine,  peptonised  foods,  and  the  like,  should  be 
pressed  upon  the  patient. 

"With  regard  to  the  effects  of  the  administration  of  drugs,  through- 
out the  whole  course  of  the  case,  for  purposes  other  than  the  relief  of 
pain,  our  exact  knowledge  is  almost  nothing.  We  know  that  alcohol 
in  suitable  doses  produces  a  certain  amount  of  stimulation  and  a  sense  of 
well-being,  and,  if  it  can  be  well  borne  and  duly  eliminated  from  the 
system,  there  does  not  seem  to  be  any  sufficient  reason  for  denying 
some  reasonable  amount  to  those  to  whom  it  would  be  a  comfort.  It 
may  be  considered,  in  fact,  as  an  auxiliary  to  morphia  and  soporific 
drugs;   and,  in  the  latest  stages,  one  of  the  means  of  euthanasia. 

Arsenic  has  so  long  had  a  reputation  in  the  treatment  of  cancer, 
Avhether  internally  or  by  topical  application,  that  we  are  disposed 
to  administer  it  rather  lest  we  should  be  depriving  the  patient  of  an 
advantage  than  from  any  firm  faith  in  its  usefulness.  If  it  can  be  borne, 
the  combination  of  arsenic  and  iron,  either  as  a  pilule  of  arseniate  of 
iron,  or  as  a  natural  arsenical  water,  is  probably  beneficial.  I  have 
been  in  the  habit  of  recommending  the  constant  use  of  arseniate  of 
iron  to  patients  after  total  hysterectomy,  and  my  impression  is  that  a 
certain  amount  of  advantage  has  been  obtained  from  it. 

Quinine  is  recommended  as  a  means  of  diminishing,  as  far  as  pos- 
sible, the  effects  of  absorption  from  the  septic  area,  but  it  is  not  well 
borne  by  the  stomach  of  a  cancer  patient,  and  in  fact  it  is  only  in  the 
comparatively  early  stage  that  it  can  be,  as  a  rule,  administered  with 
advantage. 

The  specific  treatment  by  Chian  turpentine  need  only  be  mentioned 
in  passing  as  one  of  the  numerous  empiric  methods  of  treatment  which 
excited  hopes  for  a  time,  among  some  persons  to  whom  a  disease  is  an 
entity,  only  to  be  abandoned  like  its  forerunners  in  favour. 

An  Complkation  of  Prerjnancy.  —  Malignant  disease  of  the  cervix  as 
a  complication  of  pregnancy  and  labour  is  a  subject  of  great  scientific 
interest  and  practical  importance.  Owing,  however,  to  the  comparative 
infrequency  of  its  occurrence,  to  the  great  variations  in  the  clinical  facts 
of  the  cases,  and  to  the  intermixing  of  ethical  considerations  of  greater 
or  less  importance,  it  is  impossiljlo  to  make  a  satisfactory  classification 
of  the  cases,  or  to  lay  down  any  rules  of  universal  a])i)]ication. 

When  the  disease  is  not  far  advanced,  and  it  is  olwious  that  the  uterus 
could  be  extirpated  without  unusual  danger  or  difficulty,  the  folloAving 
question  naturally  arises  with  regard  to  the  interruption  of  pregnancy :  — 
If  the  pregnancy  is  not  far  advanced,  are  we  to  wait  to  the  full, 
or  nearly  to  the  full  term,  and  permit  the  cancer  to  grow  rapidly,  as  it 


MALIGNANT  DISEASES    OF   THE    UTERUS  711 

is  certain  to  do  in  the  meantime  ?  or  are  we  to  interrupt  labour  without 
any  consideration  for  the  life  of  the  foetus  in  utero  ?  "With  regard  to 
the  interruption  of  pregnancy,  which  is  not  effected  at  the  same  time  as 
the  final  operation  on  account  of  the  cancer,  we  must  keep  in  mind  the 
great  danger  of  septic  infection  during  the  puerperium  owing  to  the 
manipulations  of  the  malignant  new-growth  and  its  continued  presence. 
Another  consideration,  which  must  influence  to  some  extent  the  judgment 
of  those  with  whom  the  decision  lies,  is  the  prospect  of  inherited  ten- 
dency to  malignancy  in  a  child  developing  in  the  uterus  of  a  mother 
already  the  subject  of  the  disease  in  a  more  or  less  advanced  stage ; 
even  though  ordinarily  heredity  may  be  almost  disregarded  as  a  factor 
in  the  etiology  of  cancer.  But  there  is  a  stronger  argmnent  against 
giving  too  much  heed  to  the  child  in  the  adoption  of  any  modern 
method  of  obstetric  treatment.  If  we  compare  the  results,  so  far  as  the 
child's  life  is  concerned,  of  the  earlier  practice  in  cases  of  cancerous  com- 
plications with  those  obtained  since  operation  has  been  more  largel)' 
resorted  to,  we  find  that  in  Cohnstein's  statistics,  published  in  1S73, 
only  42  children  survived  in  116,  that  is,  36-2  per  cent.  In  the  142 
cases  quoted  by  Theilhaber,  in  giving  the  statistics  for  twenty  years  up 
to  1893,  the  proportion  surviving  was  46'4  per  cent. 

Xow  a  large  number  of  these  survivors  of  birth  die  within  the  first 
few  weeks  :  experience,  therefore,  shows  that  in  any  event  the  danger  to 
the  child  on  the  expectant  plan  of  treatment  is  very  great. 

If  Ave  may  infer  the  opinions  from  the  j^ractice  of  those  who  have 
published  cases,  one  would  be  led  to  the  conclusion  that  the  life  of  the 
foetus  has  not  been  a  matter  of  much  concern  to  most  of  them,  and  that 
operations  have  been  undertaken  almost  entirely  in  the  interests  of  the 
mother.  Even  the  great  exception  to  this  rule  appears  to  show  that  the 
another's  life  and  Avelfare  should  be  our  main  consideration  in  deciding 
the  time  and  method  of  operation.  The  great  exception  is  the  case 
in  which  the  disease  has  not  been  discovered  until  towards  full  term, 
or  when  labour  has  begun.  The  case  has  then  usually  become  inoperable 
as  a  case  of  cancer ;  and  the  only  thing  that  can  be  done  is  to  endeavour 
to  save  the  child  by  the  Csesarean  section,  which  also  enables  the  mother 
to  live  as  long  as  the  disease  will  permit. 

The  operable  cases  of  cancer  of  the  pregnant  xiterus  readily  divide 
themselves  into  three  largely  comprehensive  classes.  Yet  some  operable 
and  many  inoperable  cases  can  hardly  be  classified;  and  a  study  of  the 
individual  case  must  guide  us  to  what  should  be  done  or  left  undone. 

The  first  class  includes  all  the  cases  in  which  the  cancer  is  discovered 
before  the  uterus  has  become  so  large  as  to  make  removal  of  it,  unopened, 
impossible  per  vaginam  ;  that  is  to  say,  at  the  latest  in  the  fourth  month. 

To  the  second  class  beloug  those  cases  in  which  the  pregnancy  is  too 
far  advanced  for  this  comparatively  simple  proceeding  :  in  these  eases 
in  order  to  remove  the  uterus  per  vaginam  it  is  necessary  first  of  all  to 
empty  it  by  bringing  on  premature  labour  while  the  child  is  non-viable. 
The  third  class  consists  of  those  cases  in  which  the  disease  is  not  dis- 


712 


SVSTEJ/  OF  GYN.F.COLOGY 


covered  until  the  woman  is  in  labour  and  the  child  is  living ;  then  the 
alternatives  are  ordinary  obstetric  management  and  the  Cesarean  section 
"^ith  complete  removal  of  the  uterus. 

Cases  of  the  first  class  present  the  most  favourable  features.  The 
malignancy  may  be  developing  rapidly,  and  the  amount  of  haemorrhage 
and  offensive  discharge  may  be  very  considerable;  but  owing  to  the 
evolution  of  the  uterus  the  tissues  are  remarkably  loose,  and  the  process 
of  enucleation  thus  becomes  comparatively  easy  and  safe.  It  is,  in 
fact,  the  most  favourable  method  of  treatment  if  the  condition  be  dis- 
covered in  time.  Theilhaber  gives  a  list  of  eleven  cases,  including 
the  cases  of  Olshausen,  Greig-Smith,  Brennecke,  and  Kaltenbach,  in 
which  tota  1  extirpation  without  opening  the  uterus  was  the  treatment 
in  early  pregnancy  without  a  single  fatal  result. 

When  the  uterus  is  too  large  for  vaginal  hysterectomy  pure  and 
simple,  it  is  necessary  first  to  bring  on  abortion  or  to  perform  the 
abdominal  operation.  But  the  dangers  attaching  to  Freund's  combined 
abdominal  and  vaginal  hysterectomy  are  too  formidable  to  allow  it  to  be 
entertained  except  under  unusual  circumstances.  To  empty  the  uterus 
adds  appreciable  risk  to  the  operative  proceedings,  inasmuch  as  there  is 
considerable  danger  of  infection.  It  may  be  assumed,  however,  that  no 
one  likely  to  undertake  the  management  of  such  a  case  would  operate 
without  every  possible  precaution;  or,  if  septic  metritis  occurred  in  spite 
of  such  precautions,  would  allow  it  to  run  its  fatal  course.  If,  after  the 
exercise  of  every  care  to  prevent  septic  infection  arising  from  the  induction 
of  labour  complicated  with  ulcerating  cancer,  and  in  spite  of  all  precau- 
tions, suspicious  symptoms  arise,  there  should  be  no  hesitation  in  proceed- 
ing at  once  to  the  complete  operation  of  vaginal  hysterectomy ;  but  if  no 
untoward  symptoms  arise  the  uterus  is  extirpated  at  some  convenient 
time  during  the  puerperium.  Theilhaber  gives  a  list  of  three  cases  in 
which  this  method  was  adopted,  and  the  result  was  in  each  case  satis- 
factory. Many  other  cases,  suitable  for  this  method,  are  mentioned  in 
which  unsatisfactory  and  usually  feeble  treatment  was  followed ;  with 
the  results  which  might  have  been  expected. 

In  the  third  class  referred  to,  when  the  disease  is  discovered  at  or 
about  full  term,  it  is  usually  far  advanced ;  and,  whatever  the  treatment, 
the  results  are  unsatisfactory.  If  the  os  uteri  be  dilatable  the  obstetric 
method  of  waiting  until  the  forceps  can  be  applied  appears  to  give  the  best 
results  for  mother  and  child.  In  eight  cases  quoted  the  mothers  all 
survived,  and  six  of  the  children  were  born  alive.  In  five  cases  where 
turning  was  resorted  to  three  mothers  died. 

Csesarean  section  by  any  of  the  methods,  or  combined  with  Freund's 
total  extirpation  operation,  gave  disappointing  results.  Eight  cases  of  the 
old  methfjd  of  Cicsarean  se(;tion  are  quoted  ;  all  the  mothers  died.  After 
Sanger's  Ca^sarean  operation,  of  13  women  only  three  survived  for  a 
month  or  six  weeks  ;  most  died  directly  after  the  operation.  Five  out 
of  twelve  lived  after  Porro's  operation;  and  two  out  of  six  survived 
Freund's  combined  method  of  total  extirpation. 


MALIGNANT  DISEASES    OF  THE    UTERUS 


713 


Cohnstein's  statistics  up  to  1873  show  that,  including  all  cases,  how- 
ever treated,  72  women  died  out  of  176  —  a  mortality  of  57  per  cent. 
Theilhaber's  figures  for  the  last  twenty  years  are  162  patients,  of  whom 
51  died  during  or  immediately  after  labour  —  that  is,  a  mortality  of 
31 '5  per  cent.  A  complete  study  with  recent  bibliography  will  be  found 
published  by  Hernandez  in  1894  (32). 

III.  Cancer  of  the  Body  of  the  Uterus.  — Cancer  of  the  body  of  the 
uterus  is  a  comparatively  rare  disease,  but  published  accounts  of  indi- 
vidual cases  do  not  now  indicate  it  as  so  rare  an  occurrence  as  they  form- 
erly did.  More  exact  and  earlier  observation,  and  the  inclusion  of  diffuse 
sarcoma  and  malignant  adenoma,  as,  clinically  speaking,  cancer  of  the 
body  of  the  uterus,  greatly  increase  the  number  of  cases. 

The  disease  under  consideration  is  malignant,  and  histologically  it  is 
carcinoma ;  but  in  its  clinical  features,  including  its  amenability  to  radi- 
cal and  final  surgical  treatment,  it  might  almost  be  considered  a  different 
disease  from  cancer  of  the  vaginal  portion  and  cervix.  This  difference  is 
all  the  more  striking  clinically  if  we  compare  primary  cancer  of  the  body, 
which  is  the  only  disease  under  consideration  at  present,  with  cancer  as 
found  in  the  body  when  it  is  secondary  to  cancer  of  the  cervix,  whether 
by  continuous  extension  or  by  inoculation  during  the  manipulations  of 
treatment,  which  certainly  sometimes  occurs.  The  clinical  course  of  sec- 
ondary cancer  of  the  body  is  not  separable  from  the  course  of  the  primary 
disease  from  which  it  sprung;  we  shall  here  concern  ourselves  with 
primary  cancer  only. 

At  the  time  of  writing  his  monograph,  about  ten  years  ago,  Gusserow 
had  collected  from  all  sources  only  122  cases  of  primary  cancer  of  the 
body  of  the  uterus,  including  an  indefinite  number  of  cases  of  sarcoma. 
Schroeder  diagnosed  28  cases  as  primary  cancer  of  the  body  in  812  cases 
of  carcinoma  of  the  uterus  —  that  is,  3-4  per  cent. 

Krukenberg  gave  an  account  of  the  radical  operations  for  malignant 
disease  of  the  uterus  done  at  the  University  Clinic  for  "Women  in  Berlin 
in  five  years  ending  with  April  1891.  Of  24,887  patients,  924  (3-7  per 
cent)  were  suffering  from  malignant  disease  of  the  uterus ;  and  of  these 
292  (31-6  per  cent)  underwent  surgical  operation.  The  operation  in  235 
cases  was  total  extirpation ;  and  the  disease  in  197  cases  was  carcinoma 
of  the  cervix,  in  30  carcinoma  of  the  body,  and  in  8  sarcoma  of  the  body. 
Here,  in  a  large  number  of  cases  diagnosed  beyond  question,  we  find 
malignant  disease  of  the  body  occurring  with  comparative  frequency ; 
the  relative  frequency  to  other  forms  appearing  in  a  much  higher  pro- 
portion than  in  older  statistics. 

Patlioloiiical  Anatomy.  —  Excluding  adenoma  malignum  and  diffuse 
sarcoma  of  the  body,  genuine  carcinoma  corporis  uteri  occurs  in  two 
fairly  well  defined  forms,  according  as  it  originates  (a)  in  the  parenchyma 
or  substance  of  the  iiterus,  or  (h)  in  one  or  other  of  the  constituent  ele- 
ments of  the  mucosa.  The  form  originating  comparatively  deep  in  the 
tissues  is  described  as  developing  nodules  or  spheroidal  masses  in  the 


714  SYSTEM   OF  GYNAECOLOGY 

uterine  tissue ;  these  sometimes  bulge  on  the  peritoneal  surface,  sometimes 
on  the  mucous  surface  of  the  uterine  cavity;  but  they  have  little  tendency 
to  soften  within  the  uterine  wall,  or  to  ulcerate  on  either  peritoneal  or 
mucous  surface.  This  form  is  almost  invariably  described  by  writers  on 
the  malignant  diseases  of  the  uterus,  but  it  must  be  a  rare  disease ;  and 
some  cases  which  have  been  observed  and  subjected  to  careful  examina- 
tion have  not  improbably  been  either  sarcoma  or  some  hybrid  form. 

Cancer  of  the  body  of  the  uterus  originating  in  the  mucosa  varies  in 
form  according  as  its  seat  of  origin  is  the  utricular  glands  or  the  super- 
ficial epithelium.  The  most  ordinary  case  of  carcinoma  of  the  body 
appears  to  begin  in  the  utricular  glands.  These  glands  at  the  site  of  origin 
become  blocked  by  the  proliferation  of  the  epithelial  elements.  This  is 
usually  described  by  the  pathologist  as  the  ultimate  fact  in  the  initiation  of 
the  phenomena  of  malignant  change  in  the  glands,  but  the  anatomist  —  for 
example,  Symingtonin  Quain's  Anatomy —  describes  blocking  of  the  deeper 
extremities  of  these  glands  as  a  normal  condition.  Distension  of  the 
lumen  follows  the  blocking  of  the  glands,  the  blood-vessels  in  the  inter- 
glandular  spaces  become  obliterated,  and  occasionally  deposits  of  pigment 
take  place.  At  a  comparatively  early  stage  of  this  process  hardening  or 
nodulation,  with  a  certain  amount  of  projection  into  the  lumen  of  the 
uterine  canal,  occurs  ;  and  simultaneously  there  is  development  towards 
the  muscular  tissue  of  the  uterus.  The  condition  usually  met  with  on 
examination  of  the  uterus  after  extirpation  is  that  of  an  alveolar  cancer 
deeply  invading  the  muscular  tissue  of  the  uterus ;  sometimes  with 
nodules  bulging  upon  the  peritoneal  surface,  and  invariably  with  a  cer- 
tain amount  of  ulceration  towards  the  uterine  cavity.  This  is  the  adeno- 
carcinoma described  by  Pfannenstiel.  It  is  probably  thus  designated 
because  of  a  distant  resemblance  to  gland  tissue  which  it  assumes,  but, 
as  will  be  shown  later,  it  is  not  adenoma  malignum  in  the  narrower  sense. 
When  the  cancer  begins  in  the  superficial  epithelium  of  the  uterine 
mucosa,  with  invasion  of  the  deeper  tissue,  there  is  also  a  papillary 
formation  somewhat  analogous  to  the  cauliflower  excrescence  of  the 
vaginal  portion  of  the  cervix.  It  may,  however,  take  the  form  of  mere 
superficial  proliferation  with  necrosis  and  ulceration,  forming  a  tumour 
comparatively  late  in  its  development.  This  is-  the  adeno-carcinoma 
pa];>illare  of  Pfaimenstiel.  Many  of  the  cases  described  are  probably 
epithelioma  just  as  it  occurs  in  the  cervix.  These,  as  Fritsch  points  out, 
are  mere  forms  of  the  development  of  the  disease  in  different  varieties 
of  cancer ;  and  both  forms  may  occur  in  the  same  case. 

Quite  recently,  in  some  of  the  German  special  journals,  accounts 
of  cases  called  epithelioma  (Hornkrebs)  have  appeared  from  time  to 
time.  I  have  recently  operated  upon  a  case  which  cannot  well  be 
described,  either  clinically  or  histologically,  as  other  than  papillary 
epithelioma  of  the  l)ody  of  the  uterus.  Hofmeier  describes  two 
cases  of  pavement-epithelium  cancerous  tumours  of  the  body.  In  one 
the  diagnosis  was  Vjy  the  curette  and  microscope,  as  total  extirpation 
could  not  be  effected;  in  the  other  case  both  a  tumour  of  i^avement 


MALIGNANT  DISEASES    OE   THE    UTERUS  715 

epithelial  formation  and  a  glandular  carcinoma  occurred  in  the  same 
uterus.  The  patient  was  a  virgin  of  50 ;  menopause  at  41 ;  haemorrhage 
for  1^  years;  last  half-year  purulent  discharge  in  addition.  Vagina 
narrow ;  portio  short ;  tumour  size  of  a  fist  and  a  half  bulging  through 
cervix  from  cavity  of  body ;  curette  used  for  diagnosis.  Microscopic 
examination  led  to  the  belief  it  was  sarcoma.  Operation  by  abdominal 
section  and  vaginal  method  combined.  Most  of  the  tumour  was  ultimately 
found  to  be  alveolar  cancer,  but  part  of  it  was  unquestionably  pure  flat- 
celled  epithelial  carcinoma. 

Several  such  cases  of  epithelioma  corporis  uteri  have  been  reported 
in  the  course  of  the  current  year  from  various  quarters. 

Etiology.  —  Cancer  of  the  body  is  comparatively  so  rare  that  we  have 
no  great  volume  of  statistics  to  apply  to  and  manipulate  in  the  endeavour 
to  find  some  clue  to  the  cause  of  the  disease.  One  thing  is  certain,  that 
the  most  striking  facts  connected  with  cancer  of  the  body  are  entirely 
different  from  the  corresponding  points  in  cancer  of  the  cervix.  In  cancer 
of  the  body  the  patients  are  on  the  average  much  older ;  they  are  in  a 
different  position  in  life,  usually  much  better  cared  for  from  beginning 
to  end  than  the  class  of  women  most  frequently  affected  with  cervical 
epithelioma;  and  whereas  the  subjects  of  cervical  epithelioma  are,  with 
few  exceptions,  parous,  most  of  them  multiparous,  many  of  them  remark- 
ably prolific,  the  subject  of  corporeal  cancer  is  almost  invariably  either 
elderly  maiden  or  barren  wife.  All  ray  five  cases  were  women  past  the 
menopause :  two  were  married,  but  only  one  had  been  pregnant ;  the 
rest  were  unmarried.  In  the  case  of  the  parous  patient  a  hard,  localised 
papillary  carcinoma  projected  from  the  fundus,  and  this  fact  suggests  that 
there  is  something  different  in  the  etiology  of  such  rare  tumours  from  those 
usually  met  with  in  the  body  of  the  uterus  in  elderly  Avomen.  Relevant 
to  this  supposition  is,  for  example,  the  apparent  exception  of  Ghiari's 
three  cases  quoted  by  Gusserow.  The  patients  were  married,  child- 
bearing  women,  in  whom  the  malignant  disease  made  its  appearance 
soon  after  child-bed.  But  these  cases  have  since  been  shown  to  have 
been  not  carcinoma,  but  deciduoma  malignum. 

The  symptoms  of  cancer  of  the  body  of  the  uterus  in  its  early  stages 
are  as  constant  as  the  symptoms  in  the  corresponding  stage  of  epithelioma 
of  the  cervix.  The  most  constant  is  haemorrhage  which,  in  the  post- 
climacteric cases,  is  characteristic.  In  cases  in  which  the  disease  occurs 
before  the  menopause,  the  haemorrhage  at  first  bears  some  resemblance  to 
that  which  is  caused  by  fibromyoma  of  the  uterus.  It  is  often  menorrha- 
gia,  a  profuse  and  prolonged  menstruation,  not  an  ordinary  metrorrhagia. 
Too  much,  perhaps,  has  been  made  of  this  symptom  in  the  ante-climacteric 
cases,  as  the  number  of  cases  reported  is  comparatively  small,  and  gener- 
alisation a  rather  rash  proceeding :  in  differential  diagnosis  too  little 
has  been  ma<le  of  the  fact,  that  fibroids  producing  haemorrhage  in  the 
immediately  ante-climacteric  period  of  life  are  usually  well  known  to  exist, 
and  the  cause  of  the  haemorrhage  is  consequently  known.  Besides,  such 
fibroids  are  almost  invariably  sufficiently  large  to  settle,  without  further 


7i6  SYSTEM  OF  GYXyECOLOGY 

consideration,  the  question  of  cancer  of  the  body  of  the  uterus.  In  the 
great  majority  of  cases  the  haemorrhage  has  recurred  after  the  complete 
menopause.  It  is,  as  a  rule,  comparatively  slight,  and  at  first  there  is  no 
other  symptom  at  all ;  there  may  be  lumbar  or  hypogastric  aching  from 
the  congested  condition  of  the  uterus,  and  from  the  reopening  of  the 
senile  internal  os  uteri.  The  htemorrhage  is  slight  and  continuous,  and 
there  may  or  may  not  be  some  leucorrhoeal  discharge  between  the  periods 
of  bleeding.  The  hemorrhage  often  continues  for  a  long  time  before  the 
patient  seeks  for  medical  treatment.  In  one  typical  case  of  alveolar 
cancer,  occurring  in  a  maiden  lady  of  fifty,  whom  I  had  under  treatment 
for  a  considerable  time,  finally  extirpating  per  vaginam,  the  menopause 
had  occurred  two  years  before  the  symptomatic  haemorrhage  began; 
and  the  haemorrhage  had  gone  on  for  twelve  months  before  the 
patient  mentioned  the  fact  to  anybody.  By  this  time  pain  had 
also  become  troublesome,  and  in  this  relation  of  the  symptoms  of 
hyemorrhage  and  comparatively  early  pain  we  have  one  of  the  most 
marked  differences  in  cancer  of  the  body  from  cancer  of  the  cervix. 
When  the  cancer  assumes  a  form  of  superficial  epithelial  change,  pro- 
ducing a  localised  comparatively  hard  mass  acting  like  a  foreign  body 
as  in  the  case  to  which  I  have  just  referred,  pain  comes  comparatively 
early,  and  ultimately  is  acute,  it  may  be  agonising :  it  is  also  frequently 
paroxysmal,  and  this  fact,  taken  with  the  existence  of  great  hypertrophy 
of  the  muscular  tissue  of  the  uterus,  suggests  that  pain  is  caused  by  an 
effort  of  the  uterus  to  shed  or  expel  the  diseased  endometrium  like  a 
foreign  body. 

Another  fact  in  support  of  this  view  of  the  cause  of  the  pain, 
is  that  in  such  cases  the  os  uteri  is  thinned  out  as  in  the  case  of  sub- 
mucous fibroniyoma  approaching  the  state  of  polypus  ;  and  the  cervical 
canal  is  comparatively  wide. 

In  cases  of  another  class  pain  may  be  trifling  or  almost  absent  to 
a  comparatively  late  stage  of  the  development  of  the  disease.  This 
fact  was  well  illustrated  in  two  cases  in  which  I  removed  the  uterus 
during  the  last  twelve  months.  One  was  a  typical  case  of  adenoma 
malignum,  in  which,  after  repeated  curettings,  the  disease  had  destroyed 
the  endometrium,  and  at  the  time  of  extirpation  had  left  little  but  a 
tolerably  thick  layer  of  muscular  tissue.  In  the  other  case,  from  a  site 
of  origin  proljably  in  the  utricular  glands,  comparatively  rapid  ulcera- 
tion had  advanced,  until  little  of  the  original  structure  of  the  uterus 
was  left  except  a  thin  layer  of  muscular  tissue  and  the  comparatively 
soft  peritoneal  covering.  There  was  no  hardness  or  nodulation  in  either 
case ;  and  the  steady  uniform  necrosis,  with  free  exit  for  the  liquefied 
tissue,  appeared  to  have  some  causal  reflation  to  the  immunity  from  pain. 

Even  in  the  later  stages  of  malignant  disease  of  the  body  of  the 
uterus,  there  is  no  pain  analogous  to  that  which  arises,  in  cancer  of  the 
vaginal  portion  and  cervix,  from  infiltration  of  the  parametrium  and 
interference  with  the  neighbouring  organs,  esi)ecially  with  the  urinary 
organs.     The  pain  in  the  later  stages  is  not  from  pressure,  but  from 


MALIGNANT  DISEASES    OF   THE    UTERUS  717 


peritonitis.  In  the  first  case  to  which  reference  has  been  made  the  peri- 
tonitic  pain  was  extremely  well  marked  after  paroxysmal  pain  had  dis- 
appeared under  treatment ;  and  on  extirpation  it  was  found  that  a 
considerable  quantity  of  fluid,  which  was  turbid  and  contained  shreds 
of  lymph,  had  collected  in  Douglas'  space ;  and  bosses  of  cancerous  mate- 
rial were  found  bulging  in  various  positions  upon  the  peritoneal  surface. 

Another  point  with  regard  to  the  pain  of  cancer  of  the  body,  when 
it  does  occur,  is  that  after  the  first  haemorrhage  there  is  no  symptom 
analogous  to  the  distress  from  tension  produced  by  pyometra,  which, 
by  closure  of  the  internal  os,  is  so  often  a  complication  of  epithelioma 
of  the  cervix  uteri.  "  The  intense  agonising  pain  at  an  early  stage  of 
the  disease,"  of  which  Gusserow  speaks,  appears  to  be  symptomatic 
only  of  circumscribed  adeno-carcinoma  of  the  body. 

Another  constant  symptom  of  cancer  of  the  body  of  the  uterus  is  a 
discharge  —  not  haimorrhagic  or  sanguineous.  As  compared  with  cancer 
of  the  cervix,  however,  this  symptom  comes  on  comparatively  late,  and 
the  discharge  is  diiferent.  It  is  different  in  being  thinner  and  less  turbid ; 
and,  although  foetid,  it  is  usually  much  less  offensive.  The  absence  of 
the  intensely  offensive  odour  of  cancer  of  the  cervix  is  probably  due  to  the 
absence  of  infection  by  bacteria.  It  is,  perhaps,  also  on  account  of  the 
comparatively  late  occurrence  of  infection  of  the  ulcerating  surface  that 
saprsemic  symptoms,  with  emaciation  and  cachexia,  are  comparatively 
late  in  appearing  in  a  case  of  cancer  of  the  body.  In  all  the  eases  which 
I  have  seen,  the  least  developed  of  which  was  twelve  months  from  the 
beginning  of  the  haemorrhage,  the  aspect  was  that  of  anaemia,  not  of 
cachexia;  and  in  the  last  case  of  all,  although  the  haemorrhage  had  con- 
tinued at  Intervals  for  over  a  year,  there  was  no  appreciable  loss  of  flesh. 
Emaciation  comes  after  the  anaemia,  after  the  slight  feverishness  of  the 
sapraemia;  and  the  loss  of  rest  ensues  on  the  beginning  of  pain,  the  use 
of  drugs,  and  the  unexplained  influence  upon  the  digestive  organs  of 
malignant  disease  anywhere  in  the  body. 

The  other  symptoms  and  complications  arising  from  cancer  of  the 
body  are  late  in  appearing.  Metastases  do  not  readily  occiir;  and  even 
infection  of  the  lymphatics,  after  repeated  curettings  and  interferences 
with  the  uterus,  is  strangely  slow  in  appearing.  With  the  invasion  of 
the  lymphatics  in  uterine  cancer  comes  the  reaction  of  the  connective 
tissue  invasion  Avhich  produces  fixation  of  the  uterus;  and  in  the  absence 
of  lymphatic  infection  in  cancer  of  the  body  is  ]U'obably  to  be  found  the 
explanation  of  the  fact,  that  in  cancer  of  the  body  the  uterus  is  seldom  if 
ever  found  to  be  fixed  until  a  very  advanced  stage  of  the  disease  is  reached. 

My  first  case  of  extirpation  of  the  uterus  well  illustrates  the  extent 
to  which  local  and  general  changes  may  occur,  and  the  length  of  time 
which  may  be  occupied  by  these  changes  without  lym])hatic  invasion  or 
metastases ;  so  that  the  capacity  for  full  recovery  still  remains.  After 
repeated  curettings,  the  administration  of  drugs,  and  frequent  haMuor- 
rhage  and  foul  discharge  during  an  unnecessary  delay  of  twelve  months, 
which  was  owing  to  the  decided  diagnosis  of  sloughing  fibroid  made  by 


7i8  SYSTEM   OF  GYN.-ECOLOGY 

a  well-known  gynaecologist,  my  patient  had  readied  a  point  of  emaciation 
and  suffering  from  agonising  pain  in  the  uterus,  and  disgust  produced  by 
the  foul  discharge,  which  no  general  or  local  medication  seemed  to  re- 
lieve :  thus'  the  only  alternatives  became  euthanasia  or  total  extirpation. 
The  operation  was  performed  eight  years  ago,  dating  to  the  time  of  writ- 
ing, and  within  a  week  an  entire  change  had  come  over  the  patient.  She 
Avas  free  from  pain,  had  escaped  all  the  misery  of  pervading  malodour. 
and  had  begun  to  take  food.  Since  the  time  of  complete  convales- 
cence from  her  operation  she  has,  I  have  reason  to  believe,  required 
no  medical  treatment  of  any  kind ;  and  she  is  perfectly  well  at  the 
present  time. 

Considering  the  amount  of  uterine  peritonitis  in  this  case,  and  the 
softness  of  the  bosses  on  the  peritoneal  surface  of  the  uterus,  it  is 
pretty  certain  that  if  the  patient  had  been  left  untreated  a  short  time 
longer  death  would  have  occurred  from  peritonitis,  as  has  sometimes 
been  the  case,  though  wonderfully  rarely. 

Diac/nosis.  —  In  a  case  of  cancer  of  the  body,  after  the  completion  of 
the  menopause,  there  should  be  comparatively  little  difficulty  in  establish- 
ing a  diagnosis.  It  may  be  difficult  or  impossible  to  say  what  form  of 
malignant  disease  exists ;  but  the  diagnosis  of  malignancy  should  not  be 
difficult,  and  this  is  sufficient  for  all  practical  purposes.  The  particular 
form  of  malignant  disease  is  seldom  diagnosable  from  the  symptoms  and 
from  the  examination  of  shreds  of  endometrium ;  and,  when  the  extirpated 
viteriis  is  in  the  hands  of  the  pathologist,  it  is  sometimes  even  still  a  mat- 
ter of  doubt.  When  malignant  disease  of  the  body  occurs  before  the  meno- 
pause, there  are  only  two  other  conditions  or  combinations  of  these  which 
can  produce  symptoms  likely  to  lead  a  well-informed  practitioner  into 
difficulty :  these  are  necrosing  fibroid  polypus  or  subserous  fibromyoma- 
tous  tumour,  and  incomplete  early  abortion  with  slight  bacterial  infection. 

In  the  case  of  cancer  of  the  body,  the  cervix  on  digital  examination 
gives,  as  a  rule,  the  impression  of  being  unchanged.  The  lips  may  be 
thinned  out  in  cases  of  the  class  already  referred  to;  but  as  a  rule  no 
such  change  has  taken  place.  It  is  stated  also,  by  some  authors,  that  the 
exposure  of  the  vaginal  portion  by  the  speculum  does  not  assist  the  diag- 
nosis. In  the  cases  which  have  come  under  my  observation  there  has  always 
been  a  change  in  the  endometrium,  even  of  the  vaginal  portion.  There  is 
a  suggestion  of  activity  and  hyperemia,  an  indescribable  change  of  colour 
of  an  unwholesome  kind.  It  is  a  hypei'ajmia  confined  to  the  mucous  lining 
without  any  other  obvious  change ;  and  this  change  of  colour  and  consist- 
ency is  seen  in  an  extremely  marked  form  even  after  total  extirpation  of 
the  uterus.  On  physical  examination,  per  vaginam  and  bimanually,  the 
uterus  may  not  be  found  greatly  changed  in  size  or  shape.  In  old 
virgins  the  examination  should  be  invariably  made  with  the  aid  of  an 
anaisthetic;  and  thc^n  it  will  be  almost  certainly  found  that  the  changes 
ascertainable  by  y)alj)ation  are  sufficiently  marked  to  arrest  attention. 
Some  slight  departure  from  the  normal  symmetry  of  the  organ,  a  greater 
or  less  departure  from  homogeneity  in  the  resistance  to  pressure,  hardness, 


MALIGNANT  DISEASES    OF   THE    UTERUS  719 

softness,  or  elasticity,  are  signs  which  must  receive  attention,  and  to 
which  due  weight  must  be  attached  in  the  diagnosis. 

When  the  diagnosis  of  marked  disease  brings  up  the  question  of  such 
a  serious  operation  as  total  extirpation,  there  is  much  to  be  said  for 
complete  exploration  by  dilatation  so  as  to  permit  the  entrance  of  the 
index  finger  into  the  cavity ;  but  this  proceeding,  not  without  danger 
in  the  senile,  is  apt  to  produce  metritis  or  endometritis  or  peritonitis 
which  may  greatly  embarrass  the  operation  and  make  it  more  dangerous. 
Such  manipulations  are  also  undesirable  on  account  of  the  ever  present 
risk  of  producing  sudden  activity  of  the  malignant  process,  which,  after 
the  production  of  a  wound,  might  possibly  result  in  lymphatic  infection 
or  in  some  other  local  infection  by  contact. 

Kapid  dilatation,  it  may  be  with  the  aid  of  an  anaesthetic,  and  the  use 
of  the  sharp  curette  or  spoon,  should  make  a  final  and  definite  diagnosis 
possible  at  once.  There  is  nothing  else  in  nature  like  the  shreds  thus 
obtained  in  a  genuine  case  of  malignant  disease.  It  may  be  objected 
that  the  broken-down  tissue  of  a  sloughing  fibroid  is  extremely  like  the 
tissue  of  a  spindle-celled  sarcoma.  This  is  one  of  the  cases  in  which 
assistance  in  diagnosis  may  be  obtained  by  comparatively  slight  and  easy 
microscopic  examination.  If  any  doubt  can  possibly  exist,  the  differences 
revealed  by  the  microscope  are  so  obvious  that  any  further  difficulty  be- 
comes hardly  conceivable ;  especially  as  there  is  always  the  history  of  the 
case  to  guide  the  judgment.  With  a  definite  history,  such  as  may  be 
obtained  in  cases  of  post-climacteric  activity  in  the  uterus,  neither  dilata- 
tion nor  curetting  may  be  necessary  to  a  diagnosis  justifying  operation. 
The  use  of  the  uterine  sound  or,  better  still,  of  a  long  surgical  probe, 
gives  the  impression  of  either  roughness  and  irregularity,  or  of  irregu- 
larity and  friability  in  the  body  of  the  uterus  that  has  no  parallel  in 
uterine  disease.  The  probe,  even  when  used  in  the  gentlest  fashion,  is 
perceived  to  sink  into  the  friable  tissue,  and  such  trifling  manipulation 
is  followed  by  an  altogether  disproportionate  amount  of  hasmorrhage. 

The  differential  diagnosis  of  ante-climacteric  cases  from  fibroid 
tumour,  or  retained  portions  of  early  blighted  ovum,  may  be  worth  con- 
sideration ;  although,  a  short  period  of  observation  being  granted  for  the 
purpose  of  diagnosis,  any  important  difficulty  is  hardly  conceivable.  In 
the  case  of  blighted  ovum  there  must  be  something  in  the  circumstances 
implying  the  possibility  of  pregnane}^  and  a  history  of  symptoms  sug- 
gesting occurrence  of  pregnancy.  Even  with  au  offensive  discharge,  the 
appearance  of  the  uterus  when  exposed  by  the  speculum  and  volsella  is 
altogether  different  from  that  which  contains  a  malignant  tumour;  the 
physiological  as  contrasted  with  the  pathological  colour  of  the  mucosa  is 
unmistakable;  and,  finally,  dilatation  permitting  the  use  of  the  curette 
must  at  once  dissipate  any  doubt  as  to  the  nature  of  the  condition :  a 
tumour,  however  friable,  is  attached ;  a  retained  portion  of  ovum  is  free 
to  come  away  on  slight  handling. 

In  the  case  of  sloughing  fibroid  in  a  woman  before  the  menopause,  the 
circumstances  may  be  such  as  to  make  the  diagnosis  doubtful  until  part 


720  SYSTEM  OF  GYN.-ECOLOGY 

of  the  tissue  is  examined ;  but  this  must  be  a  very  rare  occurrence.  The 
haemorrhage  in  the  case  of  the  fibroid  is  profuse  menorrhagia ;  the  inter- 
menstrual discharge,  if  the  patient  have  undergone  no  treatment,  is 
liydrorrhoea,  not  a  malodorous,  turbid,  sanious,  or  dirty  water  discharge. 
However  anaemic  the  patient  may  be  from  the  loss  by  haemorrhage  and 
discharge,  the  cervix,  as  revealed  by  the  speculum,  will  give  the  im- 
pression of  health. 

In  the  case  of  the  fibroid  subserous  tumour  or  polypus,  the  cervix  will 
be  comparatively  soft,  and  the  cervical  canal  more  or  less  dilated.  If  any 
doubt  continue  to  exist,  dilatation  to  permit  of  digital  examination  may 
have  to  be  effected,  and  some  portion  of  the  tissue  removed.  The  only 
possible  smooth,  circumscribed  tumour  which  can  simulate  fibromyomais 
sarcoma ;  and  an  easy,  rapid,  microscopical  examination  of  even  a  particle 
of  the  debris  of  tissue  should  finally  settle  the  question.  But  no  such 
question  need  arise.  The  naked-eye  appearances  of  the  two  tumours  are 
distinct :  the  sloughing  fibroid,  even  when  blackened  in  colour,  is  not  so 
easily  torn ;  and  Avhen  torn  it  still  shows  the  fibrous  structure  in  the 
shreds  :  the  malignant  tumour,  like  all  malignant  tissue  in  the  uterus, 
if  not  soft,  is  always  friable,  and  is  thus  easy  to  distinguish  from  any 
possible  form  of  fibromyoma  in  any  condition  which  it  ever  assumes. 

Tlie  prfxjnosis  in  cancer  of  the  body  of  the  uterus  is  much  more 
favourable  than  in  malignant  disease  of  any  other  portion  of  that  organ. 
It  is  long  after  the  initial  stages  of  the  disease  that  lymphatic  infection 
occurs  ;  and  consequently  fixation  or  even  embarrassment  of  the  move- 
ments of  the  uterus  is  an  incident  of  an  advanced  stage  only.  This  long 
continuance  of  mobility  greatly  favours  surgical  treatment ;  and,  as  a 
matter  of  experience,  comparatively  few  cases  of  this  affection  come  into 
the  hands  of  the  gynaecologists  in  an  inoperable  condition.  Krukenberg 
found  63-2  per  cent  of  cases  of  cancer  of  the  body  still  suitable  for 
operation.  The  risk  of  operation  is  said  by  some  to  be  greater,  for 
example  by  Mangiagalli  on  a  very  limited  experience  ;  but  the  prospects 
of  the  patient  who  has  recovered  are  immeasurably  more  hopeful  than 
after  recovery  from  the  same  operation  for  cancer  of  the  vaginal  portion. 

An  important  source  of  danger  in  the  course  of  the  operation  —  one 
which,  perhaps,  may  not  be  sufficiently  guarded  against  —  is  that  of  in- 
fection of  the  vaginal  or  of  the  peritoneal  wound.  In  many  of  the  cases 
of  recurrence  after  cancer  of  the  body  the  disease  could  be  distinctly 
traced  to  contact  infection. 

Krukenberg's  report  in  the  paper  already  referred  to  shows  the  f avour- 
ableprospectsafterextirpationforcancerof  the  body  in  a  very  strikingway. 

Of  2G  patients  there  Avere  free  from  recurrence  after  one  year  18 
('09-2  per  cent) ;  of  10,  after  two  years,  13  (81-2  per  cent)  ;  of  13,  after 
three  years,  \)  (GO-2  per  cent);  of  11,  after  four  years,  7  (G3-0  per  cent)  ; 
of  5,  after  five  years,  4  {i\iVl  per  cent).  The  results  would  probaljly 
have  appeared  better  still  if  information  concerning  the  missing  patients 
had  been  obtained. 

Hofmeier  mentions  one  case  of  Schrocdcr's  in  which  no  relapse  had 


MALIGNANT  DISEASES    OF   THE    UTERUS  721 

occurred  after  fifteen  years.  He  gives  also  the  history  and  results  of  23 
cases  of  operation  of  his  own.  In  4  it  was  necessary  to  perform  the 
abdominal  operation  on  account  of  the  size  of  the  uterus  or  of  complica- 
tions ;  and  the  patients  all  died  in  from  two  to  eight  days.  Of  the  19 
operated  on  per  vaginam  only  one  died  from  the  operation,  and  Hofmeier 
states  that  this  was  the  only  death  in  his  last  60  cases  of  vaginal 
extirpation.  In  two  of  the  surviving  cases,  in  which  the  disease  was  of 
long  standing  at  the  time  of  operation,  a  recurrence  took  place  in  the 
first  year,  and  one  died  suddenly  from  some  unknown  cause ;  all  the  rest 
were  well  at  the  time  of  the  report,  thus  implying  from  one  to  eight  3'ears 
of  immunity  from  the  disease  after  operation. 

Treatment.  —  When  cancer  of  the  body  of  the  uterus  is  diagnosed 
before  fixation  has  occurred,  or  before  complications  and  lymphatic  in- 
fection have  made  operation  useless,  there  is  only  one  method  of  treat- 
ment to  be  considered ;  that  is,  total  extirpation  per  vaginam. 

The  experience  of  every  year  gives  greater  confidence  to  the  advocates  of 
this  method  of  treatment.  The  technique  of  the  operation  continues  to  im- 
prove, and  all  experienced  operators  bear  testimony  to  the  smallness  of  the 
immediate  risk  to  life  and  the  excellent  prospects  of  perpetual  immunity. 

Much  harm  is  frequently  done  by  temporising  and  meddling  in  an 
ineffectual  way.  There  is  in  too  many  cases  a  history  of  medical  treat- 
ment without  examination  ;  but  it  must  be  admitted  that  it  requires 
faith  and  consciousness  of  knowledge  to  insist  upon  an  early  physical 
examination  in  the  case  of  an  elderly  maiden  lady. 

Again  we  learn  that  the  curette  has  been  used,  and  something  applied, 
and  that  the  symptoms  to  some  extent  improved ;  this  merely  implies 
in  all  probability  that  the  haemorrhage  temporarily  disappeared,  and 
thus  still  further  time  was  lost. 

In  cases  of  this  class  my  impression  is  that  the  practitioner  is  too 
shy  of  hinting  at  cancer,  which  idea  after  all  has  probably  taken  posses- 
sion of  the  patient's  own  mind  already. 

After  the  least  possible  amount  of  manipulation  consistent  with  form- 
ing a  confident  diagnosis,  the  operation  of  total  extirpation  should  be 
performed  without  delay. 

With  regard  to  the  operation  there  is  little  to  be  said  that  does  not 
apply  to  the  same  operation  for  any  other  condition.  One  danger  to  be 
avoided  is  to  prevent  contact  infection  and  consequent  early  recurrence 
from  extravasation  of  the  cancerous  fluid.  In  portio  cancer  you  may  use 
the  curette  or  scissors  as  the  first  step  in  the  operation ;  the  analogous 
step  in  corporeal  cancer  is  to  suture  the  external  os  so  as  to  prevent  any 
fluid  from  escaping. 

A  difficulty  frequently  arises  from  the  senile  condition  of  the  vagina 
and  parts  generally.  So  difficult  is  the  operation  sometimes  made  by  the 
narrowness  of  tlie  vagina  in  an  elderly  maiden  that  it  is  possible  to  com- 
plete it  only  by  making  a  free  deep  incision  through  the  perineum. 
Retractors  which,  without  considerably  lacerating  the  parts,  will  stretch 
them  to  the  uttermost,  are  also  essential. 

3a 


722  SYSTEM   OF  GYNECOLOGY 

On  account  of  this  difficulty  many  operators  have  recommended  the 
sacral  operation,  and  probably  still  more  the  combined  vaginal  and 
abdominal  method.  We  have  seen,  however,  how  terribly  fatal  Freund's 
operation  is  in  even  the  best  hands,  and  the  drawbacks  of  the  sacral 
method  are  too  serious  to  justify  it  save  imder  very  exceptional  cir- 
cumstances. I  do  not  regard  the  difficulty  of  a  narrow  vagina  and  senile 
change  as  so  great  as  it  has  been  sometimes  represented.  No  opera- 
tion of  the  kind  could  hardly  appear  more  formidable  than  one  which  I 
performed  recently  on  a  virgin  of  over  60  years ;  but  my  first  step  was 
to  make  a  free  incision  in  the  middle  line  of  the  vagina  from  an  inch 
below  the  uterus  right  down  and  through  the  perineum  to  the  sphincter. 
The  last  step  Avas  to  stitch  up  this  wound,  and  it  healed  perfectly  with- 
out reaction  or  flaw. 

In  a  far  advanced  case,  when  radical  operation  is  out  of  the  question, 
the  methods  of  giving  relief  are  exactly  those  employed  in  inoperable 
cancer  of  the  vaginal  portion  and  cervix.  The  prospect  of  keeping  the 
patient  fairly  comfortable  is  moderately  good.  Haemorrhage  can  be  kept 
within  bounds  by  means  of  the  curette  and  tampon.  The  danger  here  is 
rather  iireemia  than  septicaemia :  it  is  the  blood-poisoning  and  accom- 
panying fever  which  saps  the  strength.  Hence  the  need  for  every  effort 
to  keep  the  area  affected  as  nearly  aseptic  as  can  be  managed. 

The  complications  of  the  later  stages  of  cancer  of  the  body  differ 
considerably  in  an  anatomical  sense  from  those  produced  by  disease 
beginning  in  the  cervix ;  but  the  symptoms  are  practically  identical, 
and  the  methods  of  giving  relief  from  sufferings  are  the  same. 

IV,  Sarcoma.  —  Sarcoma  is  a  comparatively  rare  form  of  malignant 
disease  of  the  uterus.  Still  it  occurs  sufficiently  often  to  make  it  a 
matter  of  importance  to  the  practical  gynaecologist ;  it  is  not  a  mere 
matter  of  scientific  interest  to  the  pathologist.  Sarcoma  may  occur  at 
any  period  of  the  sexual  life  of  the  woman  over  20  years  of  age ;  but 
like  carcinoma  it  is  found  comparatively  often  in  the  years  just  before 
■or  just  after  the  menopause.  It  may  be  accidentally  met  with  during 
the  climacteric  period  also. 

Three  (34)  well-defined  forms  of  sarcoma  of  the  corpus  uteri  only 
will  be  described  and  treated  of  here.  The  first  is  the  form,  occurring  in 
tumours  or  masses,  which  is  so  often  mistaken  for  fibromyoma  of  the 
uterus ;  the  second  is  the  diffuse  form  found,  in  its  earlier  stages,  in  or 
near  the  endometrium,  and  bearing  a  strong  resemblance  in  its  clinical 
aspect  to  carcinoma  of  the  body  of  the  uterus.  The  third  is  sarcoma 
hotryoidos,  which  calls  for  little  notice. 

The  development  of  the  first  variety  has  a  striking  resemblance  to 
t/lie  growth  of  fibromyoma;  and,  in  fact,  all  the  details  in  the  study  of 
it  are  closely  analogous  to  those  of  fibromyoma. 

A  woman  who  is  approaching  the  climacteric  period  of  life  knows  or 
suspects  she  has  a  tumour  of  the  worn]).  She  is  led  to  look  forward  to 
abatement  of  her   symptoms  and   diminution  or  disappearance  of  the 


MALIGNANT  DISEASES   OF    THE    UTERUS  723 


tumour  with  the  cessation  of  menstruation.  Instead,  however,  of  her 
hopes  and  expectations  being  fulfilled  the  tumour,  which  may  have  been 
almost  or  altogether  stationary,  begins  to  grow,  the  haemorrhage  increases 
and  becomes  irregular,  or  it  is  replaced  in  time  by  a  thin,  watery,  sanious 
discharge.  The  hbromatous  tumour,  Avhich  has  been  painless,  begins  to 
cause  uneasiness,  and  ultimately  gives  rise  to  intolerable  pain.  The 
patient  takes  on  an  aspect  of  suffering  and  deterioration  of  health  not 
sufficiently  accounted  for  by  the  anaemia  owing  to  the  discharge  ;  she 
gradually  loses  flesh  and  assumes  a  cachectic  appearance.  When  ex- 
amined after  some  weeks  or  months  of  medical  routine  treatment  the 
uterus  is  found  to  be  fixed,  and  the  floor  of  the  pelvis  has  the  stony 
hardness  of  the  middle  stage  of  perimetritis.  The  infiltration  of  the 
tissues  of  the  broad  ligament  affects  the  ureters  and  kidneys  in  the  same 
way  as  in  the  corresponding  stage  of  cancer  of  the  cervix,  and  the  ter- 
mination may  be  the  same ;  or  symptoms  owing  to  metastases  in  dis- 
tant organs  may  arise,  and  the  fatal  termination  come  rapidly. 

These  are  the  chief  facts  in  the  history  of  a  case  of  fibrosarcoma 
uteri,  the  form  of  the  disease  which  is  due  to  the  transformation  of  fibro- 
myoma  into  sarcoma.  It  is,  I  believe,  by  far  the  most  common  of 
the  forms  of  sarcoma  of  the  uterus,  although  some  regard  the  diffuse 
form  as  the  most  frequent. 

The  second  form  of  sarcoma  of  the  body,  as  usually  described,  closely 
resembles  the  diffuse  form  of  carcinoma  of  the  uterine  mucosa ;  and  it 
is  only  to  be  clearly  distinguished  from  carcinoma  by  the  microscope. 
And  in  some  cases  there  has  even  been  a  difference  of  opinion  among 
competent  clinicians  and  liistologists  as  to  the  exact  nature  of  the 
neoplasm,  with  the  clinical  symptoms  and  the  microscopic  appearances 
of  removed  tissues  in  evidence.  In  some  of  these  cases  there  has  prol> 
ably  been  some  intermediate  condition  between  carcinoma  and  sarcoma. 

A  variety  of  this  form  is  cystic  sarcoma,  of  which  a  considerable 
number  of  cases  have  been  described  by  competent  observers.  This  is, 
pathologically,  merely  a  cystic  conformation  of  the  interstitial  variety,  or 
myoma  sarcomatodes;  but  it  has  sufficiently  special  clinical  features 
almost  to  require  a  separate  classification  and  description  for  the  efficient 
exposition  of  its  characters,  their  origin,  and  their  practical  consequences. 

Many  cases  of  sarcoma  of  the  body  of  the  uterus  have  been  described 
as  exhibiting  such  individual  peculiarities  that  it  would  not  be  possible  to 
reduce  them  to  any  classification  which  could  serve  a  useful  purpose.  We 
must  rest  satisfied  Avith  describing  all  that  pertains  to  the  individual  case. 

The  same  remark  applies  to  sarcoma  of  the  cervix.  It  is  a  com- 
paratively rare  disease,  and  the  anatomical  situation  is  the  only  thing 
sufficiently  in  common  to  serve  as  the  nexus  for  any  clinical  account  of 
the  individual  cases.  The  most  striking  form  occurring  in  the  cervix  is 
the  sarcoma  botryoides  or  grape-cluster  tumour  met  with  not  only  in 
children,  but  at  any  later  period  of  life. 

Patholofjiccd  Anatomy.  —  A.  The  interstitial  form  of  sarcoma  is 
analotrous  in  structure  to  the  fibronivonm   of   the  uterus  as  it  is  fre- 


724  SYSTEM   OF  GYXMCOLOGY 

quently,  perhaps  always,  a  transformation  of  tlie  common  benign  tumour. 
Some  of  the  cases  described,  even  when  definite  tumour  masses  existed,  ap- 
pear to  have  been  soft  sarcoma  derived  from  the  endometrium.  As  a  rule, 
the  new  growth  consists  of  one  or  more  circumscribed  masses,  not  to  be 
distinguished  by  form  or  consistency  from  myoma.  They  are  probably 
the  "  oedematous  tumours  "  which  gynaecological  surgeons  remark  on  as 
uninfluenced  in  their  growth  by  castration.  Histologically  they  show  a 
proliferation  of  round  cells,  more  or  less  replacing  the  normal  tissues  of 
the  uterine  wall.  From  Virchow  and  Schroeder  to  the  present  time  the 
vast  weight  of  authority  has  been  in  favour  of  the  view  that  interstitial 
sarcoma  is  a  malignant  transformation  or  degeneration  of  the  ordinary 
fibromyoma ;  and  many  sarcomatous  tumours  have  been  described  which 
exhibited  marked  traces  of  their  origin.  It  would  be  superfluous  to 
quote  authorities  or  describe  even  typical  cases  to  substantiate  and 
illustrate  that  which  all  recognise  and  accept. 

Von  Kahlden,  in  an  important  contribution  on  sarcoma,  while  sup- 
porting the  usually  accepted  opinion  of  the  origin  of  the  disease,  mentions 
a  case  in  which  the  seat  of  origin  of  the  tumour  was  in  the  blood-vessels, 
the  result  being  a  well-marked  angio-sarcoma. 

An  attempt  has  been  recently  made  to  prove  from  the  histological 
examination  of  operation  material  that  sarcomatous  tumours  may  arise 
from  the  muscular  tissue  elements  of  the  uterus.  Dr.  Whitridge  Williams 
has  published  a  paper,  highly  valuable  in  many  other  respects,  in 
which  he  describes  a  case  under  the  designation  of  sarcoma-like  myoma 
of  the  uterus  (myoma  sarcomatodes  uteri).  The  patient  was  a  nulli- 
parous  Avoman  of  47,  who  had  passed  the  menopause  four  years.  A  few 
weeks  before  admission  to  the  hospital  she  began  to  show  marked 
emaciation  and  Oidema  of  the  abdominal  walls  and  lower  extremities. 
The  abdomen  was  filled  with  ''large  tumour  masses  which  were 
diagnosed  as  malignant  growths  arising  from  the  generative  tract." 
The  patient  died  without  surgical  treatment.  A  detailed  description 
is  given  of  the  macroscopic  appearance  of  the  tumour,  and  of  the  results 
of  histological  investigation.  Williams  came  to  the  conclusion  that  the 
new  growth  was  derived  from  a  proliferation  of  the  muscle  cells,  and  not 
from  the  connective  tissue.  After  quoting  some  questionable  authority, 
he  proceeds  to  say,  "  It  is  evident  that  filjromyomata  may  be  transformed 
into  sarcomata  either  by  the  proliferation  of  the  connective  tissue  cells 
between  the  muscle  bundles,  or  by  the  proliferation  of  the  muscle  cells 
themselves." 

Unfortunately  this  statement  promises  to  lead  to  discoveries  too 
frequently  made  in  gynaecological  pathology.  Such  observations  do 
not  long  remain  isolated.  Dlihrssen,  for  example,  describes  a  case  of 
submucous  fibrosarcoma  in  which  he  extirpated  the  uterus.  The  tumoui- 
presented  a  marrow-like  appearance,  and  where  it  bulged  out  in  the 
uterine  cavity  it  was  studded  with  knobs  which  on  section  simulated 
brain  substance.  It  could  be  shelled  out  of  its  bed,  and  was  enclosed  in  a 
capsule  of  which,  by  careful  manipulation,  considerable  portions  could  be 


MALIGNANT  DISEASES   OF   THE    UTERUS  725 

peeled  off.  The  principal  mass  of  the  tumour  proved  to  be  a  round-celled 
sarcoma  in  which  traces  of  smooth  muscular  tissue  could  still  be  made 
out.  The  presence  of  a  capsule  and  the  remains  of  muscular  tissue  re- 
moved all  doubt.  The  tumour  was  originally  a  simple  myoma  which 
had  undergone  malignant  degeneration  four  years  after  the  menopause. 
This  tumour  formed  the  material  for  the  observations  embodied  in  a 
laborious  work  by  Pick,  in  which  he  endeavoured,  among  other  things, 
to  prove  the  muscular  origin  of  sarcoma  of  the  corpus  uteri. 

Pure  spindle-celled  sarcomas  also  occur.  These  when  they  soften 
and  disintegrate,  shedding  their  debris  through  the  uterine  canal,  give 
rise  to  symptoms  which  closely  simulate  those  of  sloughing  iibromyoma. 

The  analogy  to  fibromyoma  still  holds,  even  with  regard  to  pedun- 
culated tumours.  These  also  have  been  found  undergoing  sarcomatous 
transformation. 

Whether  such  tumours  may  have  also  a  capsule  like  a  circiunscribed 
fibroma  used  to  be  a  disputed  question.  So  many  cases  have,  however, 
been  observed  by  competent  clinicians  and  pathologists  in  the  transition 
stages,  that  it  may  be  stated  as  a  fact  beyond  further  discussion,  that 
even  malignant  tumours  of  the  body  of  the  uterus  may  have  a  distinct 
capsule,  and  may  to  this  extent  correspond  still  further  in  structure  with 
the  benign  tumours. 

B.  Diffuse  sarcoma  of  the  corporeal  mucosa  resembles,  as  has  been 
said,  the  typical  form  of  carcinoma  of  the  same  structure.  ''The  term 
diffuse  sarcoma,  sarcoma  of  the  uterine  mucous  membrane,  has  been  used 
since  Virchow's  time  to  designate  a  new  growth  proceeding  from  the 
connective  tissue  of  the  uterine  mucous  membrane,  consisting  mostly  of 
small,  closely-packed,  round  cells,  though  sometimes  of  spindle-cells,  and 
constituting  an  exceedingly  soft,  friable  infiltration  of  the  mucous  inem- 
brane"  (15). 

C.  The  third  definite  form  of  sarcoma  of  the  uterus,  sarcoma  botry- 
oides,  or  grape-like  sarcoma,  affects  the  cervix  and  occurs  in  the  years 
just  after  puberty  or  after  the  menopause.  A  few  cases  which  may  be 
included  in  this  class  have  been  described  as  sarcoma  of  the  corpus  uteri. 
The  first  case  appears  to  have  been  reported  by  Spiegelberg  in  1872. 
A  considerable  number  of  cases  were  described,  and  the  pathology  was 
discussed  during  the  next  twenty  years,  and  various  names  were  sug- 
gested, until  Pfannenstiel  published  his  monograph  in  1892,  and  pro- 
posed the  term  "  das  traubige  Sarcom,"  or  grape-like  sarcoma.  He 
opposed  the  view  that  the  disease  was  a  myxoma,  and  accepted  Weigert's 
explanation  of  the  histological  appearances,  which  indeed  in  its  essential 
points  may  be  considered  as  established.  The  cyst-like  masses,  re- 
sembling hydatid  mole,  consisted  chiefly  of  large  round  and  spindle  cells 
with  clear  spaces  separating  them.  These  spaces  were  traversed  by  a  net- 
work of  fine  thread-like  tissue  and  blood-vessels,  and  were  filled  with 
lymph  corpuscles.  The  new  growth  was  edematous,  not  myxomatous ; 
and  its  attenuated  enclosing  structure  consisted  of  squamous  epithelium, 
which  was  covered  by  a  layer  of  cylindrical  cells  with  indistinct  cilia. 


726  SYSTEM   OF  GYNECOLOGY 

The  cavities  containing  lyinpliatic  fluid  were  not  lined  with  epithelium, 
and  therefore  not  glandular.  The  growth  in  Pfannenstiel's  case  took 
its  origin  from  the  suj)erlicial  parts  of  the  mucosa  of  the  cervix,  and 
derived  its  peculiar  conformation  from  the  papillary  structures  at  its  site 
of  origin.  The  ultimate  fact  in  its  origin  appeared  to  be  some  change 
producing  proliferation  in  the  lymphatics  and  blood-vessels. 

Perhaps  the  most  important  of  recent  contributions  to  this  subject  is 
that  of  Pick,  whose  conclusions  may  be  shortly  stated. 

Sarcoma  botryoides,  as  observed  in  the  cervix  uteri  of  adult  women 
and  children,  and  the  vagina  of  children,  is  in  every  respect  a  special 
variety  of  tumour  characterised  by  its  grape-like  form.  Clinically  it  is 
extremely  malignant.  Anatomically  it  develops  from  the  most  super- 
ficial layer  of  the  mucous  membrane ;  it  spreads  first  in  the  superficial 
portions  of  the  mucosa ;  it  shows  a  strong  tendency  to  invade  the  deeper 
tissues ;  and  it  assumes  the  grape-like  form  owing  to  the  freedom  with 
which  it  may  expand  and  become  oedematous  in  the  wide  cavity  of  the 
vagina. 

The  extreme  rapidity  of  development  of  this  form  of  sarcoma  is 
accounted  for  by  its  greater  virulence  and  the  rapid  circulation  of  the 
lymphatic  stream  in  the  subepithelial  layers.  The  grape-like  conforma- 
tion is  explained  by  the  original  papillary  development,  the  freedom  for 
expansion,  and  the  dropsical  condition  brought  about  by  interference 
with  the  blood  and  lymphatic  circulation  at  the  neck  of  eacli  individual 
papillary  element. 

Symptoms  and  Course.  —  As  compared  with  carcinoma,  it  may  be  said 
that  all  the  forms  of  sarcoma  run  a  more  rapid  course  than  the  corre- 
sponding carcinomata,  after  the  symptoms  first  attract  attention. 

It  would  be  useless  to  attempt  to  separate  the  various  forms  in 
any  general  description  of  the  symptoms  produced;  indeed  it  is  not 
possible  to  establish  exact  diagnostic  symptoms  marking  them  off  from 
carcinomata,  for  whatever  suspicions  may  be  aroused  and  surmises  made, 
the  differential  diagnosis  is  only  established  by  means  of  the  microscope, 
after  operation  or  death. 

The  fibrosarcoma  gives  rise  at  first  to  the  same  symptoms  as  the 
fibromyoma.  It  is  only  when  a  tumour  begins  to  grow  rapidly  at  the 
time  it  ought  to  diminish  that  the  suspicion  of  malignancy  is  excited. 
It  may  be  laid  down  as  a  rule,  with  few  if  any  exceptions,  that  an 
apparent  fibromyoma,  which  begins  to  grow  at  the  menopause,  is  under- 
going sarcomatous  transformation.  The  apparent  exception,  a  case  of 
activity,  not  of  enlargement,  in  a  post-climacteric  uterus  which  is  the 
seat  of  tumour,  is  the  separation  of  a  submucous  fibromyoma  which  has 
undergone  a  certain  amount  of  shrinking,  and  has  become  starved  by 
interference  with  its  nutrition  due  to  senile  changes. 

When  post-climactei'ic  growth  of  the  tumour  occurs  two  symptoms 
soon  appear.  One  is  pain  owing  to  tension  resulting  from  the  rapid 
growth,  and  often  from  invasion  of  the  circumuterine  connective  tissue  ; 
the  other  is  marked  deterioration  in  the  general  health.     Quite  recently 


MALIGNANT  DISEASES   OF   THE    UTERUS  727 

I  performed  abdominal  hysterectomy  on  a  patient  suffering  extremely 
from  pressure  symptoms,  owing  to  jamming  of  a  large  uterine  tumour  in 
the  pelvis.  The  case  had  been  erroneously  diagnosed  as  sarcoma,  although 
the  patient  had  not  reached  the  menopause.  I  operated  for  fibromyoma, 
although  it  would  be  difficult  to  state  explicitly  the  grounds  for  con- 
fidence in  that  diagnosis,  apart  from  the  aspect  and  the  absence  of  marked 
deterioration  of  health.  We  may  observe  distinct  anaemia  from  bleeding 
fibroid,  but  there  is  more  than  antemia  in  the  case  of  fibromyoma  sarco- 
matosum :  there  is  an  aspect,  accompanied  by  marked  loss  of  strength, 
which  the  patient  takes  on  early ;  the  expression  of  suffering  comes  later. 
A  few  years  ago  I  was  consulted  in  the  case  of  an  unmarried  woman  of  the 
])ost-climacteric  age  who,  until  a  week  or  two  before,  had  been  under- 
going the  electric  treatment  for  fibroid  tumour.  The  pelvis  was  filled 
by  a  hard,  irregular  mass,  and  the  uterus  was  absolutely  immovable. 
The  history  of  tumour  had  existed  for  years.  There  was  profuse 
haemorrhage  and  much  pain,  but  no  offensive  discharge.  From  the  ap- 
])earance  of  deterioration  of  health,  including  loss  of  flesh,  the  diagnosis 
(jf  rapidly  growing  sarcoma  was  given,  and,  after  the  patient's  death, 
which  occurred  a  few  weeks  later,  this  opinion  was  proved  to  be  correct. 

If  the  neoplasm  is  developing  from  a  submucous  fibromyoma  or 
polypus,  there  will  be  severe  haemorrhage  and  pain  from  the  efforts  of 
the  uterus  to  expel  the  tumour.  If  such  a  tumour  be  removed  there  is 
soon  recurrence ;  but  the  expulsion  of  several  polypi  at  intervals,  although 
suspicious,  is  not  to  be  considered  diagnostic  of  malignancy.  "  Kecurreut 
fibroid,"  and  therefore  malignant  it  may  be ;  but  it  may  be,  and  in  the 
preclimacteric  case  more  probably  is,  merelj^  expulsion  of  several  pre- 
viously existing  submucous  fibroids  which  have  shrunk  on  account  of 
senile  changes. 

As  the  sarcomatous  neoplasm  advances  in  growth,  in  addition  to 
occasional  violent  haemorrhage,  it  may  cause  a  sanious  hydrorrhcea ; 
even  though  it  is  not  necrosed.  This  discharge  sooner  or  later  takes  on 
an  offensive  odour.  The  tumour,  moreover,  may  become  gangrenous, 
and  give  rise  to  septicaemia  more  or  less  acute,  according  as  surgical 
treatment  has  been  attempted  or  not. 

Owing  to  the  intense  anaemia,  sapraemia,  and  marasmus,  death  is 
readily  produced  by  peritonitis  or  obstruction  of  the  intestines  ;  or  from 
pressure  on  the  ureters.  It  is  often  preceded  by  oedema  of  tlie  abdomi- 
nal walls  and  legs,  partly  from  pressure,  partly  from  failure  of  the  heart. 

In  the  diffuse  mucous  form  of  sarcoma  the  symptoms  are  not  dis- 
tinguishable from  carcinoma  affecting  the  same  structures.  There  is 
usually  a  profuse  leucorrhoea  occasionally  mixed  with  blood ;  and  severe 
haemorrhage  may  occur,  but  not  as  a  rule.  It  is  ratlier  persistent  and 
irregular. 

Pain  as  a  symptom  is  variable.  It  is  as  a  rule  more  severe  than  in 
the  corresponding  stage  of  any  other  form  of  malignant  disease  of  the 
body,  but  cases  have  been  mentioned  in  which  it  was  entirely  absent. 
The  pain  probably  depends  upon  several  causes.    It  may  be,  as  suggested 


728  SYSTEM  OF  GYNECOLOGY 

by  Gusserow,  that  it  depends  upon  the  depth  to  which  the  sarcomatous 
infiltration  has  penetrated,  and  that  the  immediate  cause  is  "  some  mor- 
bid change  in  the  terminal  nerve  filaments."  From  the  frequency  with 
which  the  os  internum  is  partially  or  wholly  blocked  from  within  by  the 
infiltration  resulting  occasionally  in  hydrometra  or  pyometra,  the  pain 
must  be  sometimes  owing  to  efforts  of  the  uterus  to  expel  its  contents. 
It  is  then  partly  a  uterine  colic. 

Later  in  the  course  of  the  disease  the  peritoneum  may  become 
invaded,  or  the  disease  may  penetrate  the  walls  of  some  of  the  neigh- 
bouring organs. 

Metastases  are  rarer  than  in  the  fibrosarcomata,  but  the  diffuse 
mucous  form  extends  continuously  at  a  greater  rate. 

Diagnosis. — With  the  exception  of  the  rare  sarcoma  botryoides  of 
the  cervix,  sarcoma  cannot  be  positively  diagnosed  Avithout  microscopic 
examination. 

The  first  thing  to  be  done  is  to  observe  the  clinical  symptoms  care- 
fully, and  endeavour  to  settle  the  question  of  malignancy.  If  the  malig- 
nant character  of  the  tissue-changes  in  the  uterus  be  once  definitely 
established  and  acted  upon,  there  will  be  time  to  distinguish  by  suit- 
able means  the  particular  kind  of  tumour  from  all  others  which  it 
simulates. 

In  the  case  of  the  fibromyomatous  sarcoma  there  are  two  points 
specially  deserving  attention  :  (a)  the  rapid  growth  at  or  about  the  meno- 
pause of  a  tumour  previously  known  to  exist,  and  (&)  a  more  marked 
ansemia  and  deterioration  of  health  than  is  ever  found  associated  with 
the  same  stage  of  growth  of  a  benign  tumour. 

The  growth  of  the  tumour  may  be  so  rapid  as  to  suggest  the  French 
designation  r/rossesse  cancereuse  sometimes  applied  to  such  cases ;  and, 
however  smooth  and  symmetrical  the  tumour,  the  early  occurrence  of 
fixation,  as  compared  with  cancer,  is  a  point  of  some  diagnostic  value. 

The  profuse  sero-sanguinolent  discharge,  like  hydrorrhoea  from 
sloughing  fibroid  but  usually  more  turbid  even  before  interference,  may 
excite  suspicion.  The  greater  or  less  density  or  softness  or  sense  of 
resistance  conveyed  on  palpation  of  the  tumour  does  not  afford  any 
help  to  diagnosis. 

Attempts  to  diagnose  the  mucous  form  at  a  comparatively  early  stage 
by  means  of  scrapings  for  microscopic  examination  have  strikingly  failed. 
It  will  be  remembered  that  when  arguments  for  and  against  total  extirpa- 
tion were  being  eagerly  sought  fot  in  the  early  days  of  the  controversy, 
Abel  and  Landau  discovered  that  the  endometrium  of  a  uterus  affected 
by  malignant  disease,  even  of  the  vaginal  portion,  was  the  seat  of  sar- 
comatous degeneration.  The  discovery  was  hailed  as  important,  and 
its  truth  was  supported  by  numerous  observations.  It  is  now,  however, 
universally  admitted  that  the  appearances  described  are  due  to  changes 
resulting  from  congestion  of  the  endometrium,  and  that  similar  changes 
occur  in  the  corporeal  mucosa  of  the  fibroid  uterus. 

Prognosis. — There  is  a  remarkable   difference   of   opinion   among 


MALIGNANT  DISEASES    OF   THE    UTERUS  729 

writers  on  the  subject  as  to  the  comparative  nnfavourableness  of  the 
prognosis  in  sarcoma  and  in  carcinoma. 

All  are  agreed  as  to  sarcoma  that  it  is  malignant ;  no  patient  once 
affected  ever  recovers. 

It  is  said  by  some  to  be  slower  in  its  development  in  the  earlier  stages 
than  carcinoma,  and  when  treated  by  early  operation  to  be  less  likely  to 
recur  than  carcinoma.  V.  AVinckel  commits  himself  to  this  opinion,  but 
adds  that  if  operation  be  impossible  the  disease  is  generally  more  rapidly 
fatal  than  carcinoma.  This  implies  that  the  later  stages  of  inoperable 
sarcoma  are  more  rapid  than  in  carcinoma,  although  the  earlier  develop- 
ment is  slower.  Reports  of  individual  cases  do  not  seem  quite  to  sup- 
port this  symmetrical  generalisation. 

Most  are  agreed  that  if  surgical  interference  is  once  begun,  the  down- 
ward course  is  rapid  if  the  uterus  and  affected  area  be  not  completely 
swept  away.  The  reported  exceptions  are  comparatively  few,  although 
some  of  them  are  striking,  In  recent  years,  when  much  attention  has 
been  devoted  to  radical  surgical  measures,  a  tolerable  consensus  of  opinion 
has  been  formed  to  the  effect  that  sarcoma  recurs  sooner  than  carcinoma 
after  extirpation. 

Treatinent  of  Sarcoma.  —  The  treatment  is  radical  or  symptomatic. 
The  radical  treatment  is  the  same  as  for  carcinoma.  If  the  uterus  be 
movable,  and  there  be  no  metastases  or  invasion  of  the  vagina,  the  treat- 
ment is  total  extirpation.  This  should  be  done  by  the  vaginal  method  if 
possible;  if  this  be  impracticable,  then  by  the  combined  abdominal  and 
vaginal  methods.  If  there  be  infiltration  of  the  sacro-uterine  folds  or 
broad  ligaments,  even  though  extirpation  is  still  possible,  the  advantages 
obtained  in  operating  at  so  late  a  period  in  carcinoma  are  not  to  be  ex- 
pected. Hecurrence  takes  place  all  the  sooner,  and  the  progress  of  the 
disease  afterwards  is  so  much  the  more  rapid. 

V.  Adenoma  Malignum.  —  The  question  whether  adenoma  malignum 
should  be  considered  a  distinct  class  of  cancer  of  the  uterus  is  not  yet  set- 
tled. Such  observations  as  have  been  published  tend  to  the  conclusion  that 
it  is  a  definite  form  of  disease;  just  as  epithelioma  is  a  definite  form  of 
malignant  disease  of  the  cervix :  and  the  separate  study  and  description 
of  it  would  more  rapidly  bring  about  its  elucidation  and  more  effective 
treatment. 

It  is  a  post-climacteric  form  of  malignant  disease  almost  restricted  to 
the  body  of  the  uterus.  It  is  too  early  in  the  history  of  the  subject  to 
generalise,  but  it  may  be  safer  and  more  iiseful  in  practice  to  assume 
that  adenoma  occurring  in  the  bodv  of  the  post-climacteric  uterus  is 
always  a  malignant  disease,  and  ought  to  be  treated  as  such. 

Take  as  an  illustration  the  case  of  a  patient,  age  57,  married  twenty- 
six  years ;  never  pregnant ;  menopause  in  her  49th  year.  For  several 
years  a  history  of  slight  discharge  without  colour  and  Avithout  offensive 
odour.  The  family  doctor,  several  years  ago,  removed  a  small  bunch  of 
slimy  polypi  that  projected  from  the  os  uteri ;  after  Avhich  there  was 
some  diminution  in  the  discharge.     In  1893,  the  discharge  had  become 


730  SYS  TEA/   OF  GYNMCOLOGY 

so  profuse  that  tlie  patient  again  consulted  her  doctor.  There  was  slight 
occasional  haemorrhage  also,  though  the  amount  of  bleeding  was  never  an 
important  feature  among  the  symptoms.  The  doctor  sent  her  to  consult 
a  well-known  gynaecologist,  who  spoke  of  some  important  operation,  and 
on  the  patient's  return  home  the  uterus  was  dilated  and  curetted,  some 
more  polypi  being  removed.  After  this  operation  the  discharge  never 
ceased,  and  it  was  sometimes  very  profuse.  After  several  months  of 
'•  convalescence "  at  the  sea-side  she  returned  home  much  worse  in 
health,  and  I  had  the  opportunity  of  examining  her  soon  after.  The 
discharge  had  usually  been  thin  and  somewhat  slimy,  and  only  quite 
recently  had  it  become  at  all  offensive  in  smell. 

From  the  history  obtained  at  the  first  interview,  and  the  character 
of  the  discharge  (to  the  touch  it  felt  like  thin  ovarian  tumour  fluid),  I 
concluded  that  it  was  a  case  of  malignant  disease  of  the  body  of  the 
uterus,  and  total  extirpation  was  suggested.  Before  operation,  however, 
a  much  better  opportunity  of  examining  the  patient  Avas  obtained;  and, 
although,  on  superficial  observation,  the  cervix  uteri  appeared  intact  and 
healthy,  there  was  a  peculiar  dark  coloured,  velvety  condition  of  the 
endometrium  of  the  cervix :  on  passing  a  surgical  probe  cautiously 
through  the  os  internum  the  body  was  found  to  be  enlarged,  and  the 
probe  could  be  felt  to  penetrate  the  tissues  round  the  cavity.  The 
operation,  which  was  extremely  difficult  owing  to  the  narrowness  of  the 
vagina,  was  accordingly  performed  in  November  1894,  and  a  year  later 
the  patient  was  described  as  having  been  completely  restored  to  health. 

Microscopic  examination  of  the  uterus  showed  the  muscular  tissue 
penetrated  everywhere  —  in  some  parts  almost  to  the  peritoneal  covering ; 
but  in  considerable  patches  near  the  cavity,  Avhere  the  neoplasm  had  not 
completely  ulcerated,  the  characteristic  glandular  appearance  of  malig- 
nant adenoma  could  be  very  definitely  made  out. 

The  first  case  of  adenoma  of  the  body  of  the  uterus  was  described 
by  Matthews  Duncan,  and  is  quoted  in  full  by  Sir  John  Williams  in 
his  work.  The  chief  points  to  be  noted  are  :  the  patient,  a  virgin ;  her 
age,  52 ;  previous  length  of  illness,  two  years ;  and  some  uterine  symj)- 
toms.  There  is  a  history  of  previous  good  health ;  then  a  copious  red, 
watery  discharge  ;  later,  haemorrhage  and  the  passing  of  fleshy  pieces  ; 
the  discharge  continued  without  intermission  and  was  not  foetid. 
There  was  pain  in  the  back,  then  irregularly  severe  pain  in  the  ab- 
domen, and  still  later  great  deterioration  of  the  general  health.  Then 
follows  a  description  of  the  condition  of  the  uterus,  the  naked-eye  ap- 
pearance of  the  growth,  and  the  method  of  treatment;  and  then  the 
author  expresses  the  opinion  that  "  it  will,  before  many  months  are  past, 
show  the  terrible  characters  of  undoubted  cancer."  This  prediction  was 
soon  fulfilled.  The  microscopic  appearance  was  obscured  by  haemorrhage 
into  the  tissues  of  the  j)arts  removed,  but  it  showed  canals  lined  with  a 
continuous  stratum  of  cylindrical  epithelium.  Other  details  are  giveii, 
such  as  we  read  in  more  recent  observations  made  in  material  obtained 
by  extirpation,  and  therefore  more  favourable  for  examination. 


MALIGNANT  DISEASES    OF   THE    UTERUS  731 

We  have  little  definite  knowledge  about  adenoma  malignum  as  dis- 
tinguished from  carcinoma  of  the  body  of  the  uterus.  It  could  hardly  be 
otherwise.  Our  knowledge  of  cancer  as  affecting  the  body  of  the  uterus 
does  not  extend  back  much  more  than  twenty  years,  when  its  very 
existence  as  a  primary  disease  was  still  a  subject  of  controversy. 

The  material  obtained  by  hysterectomy  enabled  Ruge  and  Veit  (40) 
to  produce  their  celebrated  essay  on  cancer  of  the  uterus,  based  on  exact 
clinical  and  anatomical  observations  of  twenty-one  cases.  Since  then 
vast  additions  have  been  made  to  the  literature  of  the  subject,  and  more 
exact  observations  show  that  cancer  of  the  body  is  of  more  common 
occurrence  than  was  formerly  supposed.  Sir  John  Williams,  at  the  time 
his  work  was  published  in  1888,  had  seen  only  seven  cases  in  all  his 
experience ;  whilst  Schmidt  (46),  in  the  most  recent  account  of  work  in 
a  German  clinic,  gives  nine  cases  of  cancer  of  the  body,  including  two 
of  sarcomatous  degeneration  of  myoma  out  of  a  total  of  39. 

How  many  of  the  cases  described  as  cancer  of  the  body  were  malignant 
adenoma  it  is  impossible  to  say,  as  very  fcAv  observers  have  given  suffi- 
ciently exact  descriptions  of  the  histology ;  and  those  who  have  observed 
and  described  exactly  are  divided  in  opinion  as  to  the  proper  term  to 
apply  to  it  —  whether  malignant  adenoma  or  adeno-carcinoma.  By  its 
symptoms  it  has  not  been  differentiated  from  cancer  of  the  bod}^,  although 
some  of  its  characters  are  sufficiently  well  marked. 

Ruge  (42)  maintains  that  the  benign  form  is  a  mere  product  of 
inflammation ;  it  is  an  endometritis  glandularis  hypertrophica,  whilst 
the  malignant  form  is  closely  related  both  clinically  and  anatomically 
to  carcinoma.  Ziegler  calls  it  adenoma  destruens,  but  ranks  it  among 
the  carcinomata. 

Flirst  described  a  case  of  adenoma  of  the  cervix,  which  was  treated 
by  the  curette  and  Pacquelin's  cautery.  In  a  year  and  a  half  after- 
wards carcinoma  of  the  body  of  the  uterus  had  developed  itself.  He 
compared  the  simple  glandular  hyperplasia  with  the  destructive  form, 
and  concluded  that  the  latter  shows  its  malignant  character  comparatively 
early  by  invasion  of  the  deeper  structures,  and  by  the  gland  tubules 
assuming  an  irregular  form  with  increase  of  their  epithelium.  In 
every  such  case  he  would  extirpate  the  uterus,  relying  entirely  on  the 
microscopic  appearances. 

This  case  points  to  the  development  of  genuine  carcinoma  from 
typical  adenoma;  just  as  Ave  find  that  recurrence  after  epithelioma  of 
the  portio  vaginalis  may  show  itself  as  true  carcinoma.  The  argument 
that  adenoma  is  therefore  only  a  form  of  carcinoma  applies  with  equal 
force  to  cancroid  of  the  portio  vaginalis. 

Hofmeier  maintains  that  adenoma  malignum  should  be  placed  in  a 
separate  category  from  carcinoma.  He  calls  attention  to  the  facts  of  its 
development.  It  consists  of  tubules  of  cylindrical  epithelium  wliicli  may 
lie  side  by  side,  or  form  coils  by  twisting  about  one  another  with  little 
or  no  connective  tissue  layer  intervening.  It  penetrates  and  destroys 
the  underlying  parenchyma,  and  recurs  after  operation.    He  accepts  the 


732  SYSTEM   OF  GYNECOLOGY 

statement  made  by  another  observer  that  the  benign  form  does  not 
invade  the  underlying  uterine  muscle  ;  and  that  an  important  fact  for 
diagnosis  lies  therein. 

His  statements  are  largely  controversial  in  reference  to  Huge  and 
Yeit,  on  the  one  hand,  and  to  Abel  and  Landau  on  the  other  ;  and  they 
depend  chiefly  upon  his  belief  in  microscopic  diagnosis.  The  important 
clinical  characters,  and  the  local  tissue  changes  ■which  differentiate  it  from 
carcinoma,  have  been,  however,  described  nowhere  better  than  in  a  case 
reported  from  "Wurzburg  by  Landerer.  This  was  clearly  a  case  of 
adenoma  malignum,  although  the  author  holds  on  throughout  to  his  pre- 
conception as  to  cancer.  The  patient  was  a  married  woman,  aet.  48 
years  ;  had  borne  five  children,  the  last  fifteen  years  before ;  for  many 
years  menstruation  had  been  irregular,  and  for  four  years  she  had  suf- 
fered from  almost  constant  coloured  discharge.  No  pain  or  subjective 
symptoms.  On  examination  (April  1891)  the  uterus  was  found  enlarged 
to  the  size  of  a  man's  fist;  it  presented  some  irregularities  in  form  and 
resistance  ;  the  sound,  passed  over  four  inches,  indicated  soft  masses  and 
projections,  and  great  congestion  of  mucosa.  Portio  vaginalis  normal, 
multiparous.  Abrasion  of  the  mucosa  with  curette  proved  it  vastly 
hypertrophied  and  softened :  two  teaspoonfuls  of  shreds  of  tissue  were 
thus  obtained.  Microscopic  examination  led  to  diagnosis  of  endometritis 
glandularis  hypertrophica. 

Some  futile  treatment  followed.  Temporary  cessation  of  haemorrhage ; 
relapse  and  readmission  to  hospital,  December  1891 .  Patient  suffering 
then  from  pain  to  some  extent,  loss  of  flesh  and  failure  of  strength, 
and  extreme  anaemia.  Cervical  part  examined ;  still  apparently  normal : 
corporeal  part  large,  hard,  nodular,  and  congested,  but  perfectly  movable. 
Repetition  of  curetting,  microscopic  examination  of  debris,  and  report 
with  much  circumstance.  Result :  Diagnosis  of  endometritis  chronica 
glandularis  hyperplastica,  which  condition  was  assumed  to  be  produced 
by  the  presence  of  a  myomatous  interstitial  tumour.  Patient  sent  out 
with  prescription  for  hydrastis  canadensis. 

Relapse  once  more ;  haemorrhage,  general  pain,  great  loss  of  strength, 
anaemia.  Author  regretted  that  there  was  not  a  third  curetting,  zu  diag- 
nostischen  Zwecken;  but  total  extirpation  was  resolved  on,  and  carried 
out  on  March  31,  1892  —  that  is  to  say,  after  five  years  of  haemorrhage 
and  one  year  of  treatment.     Patient  recovered. 

There  is  the  usual  prolix  description  of  the  macrosco])ic  and  micro- 
scopic appearances  of  the  uterus.  There  was  not  a  nodule  of  myoma 
anywhere,  but  there  was  great  hypertrophy  of  apparently  normal  mus- 
cular tissue,  with  occasional  small  cysts  disseminated  through  it,  and  there 
were  polypous  projections  from  the  walls  into  the  cavity  of  the  uterus. 
Histologically  the  growth  of  gland  cells  was  the  most  prominent  feature; 
the  dee[)  layers  of  the  mucosa  showed  that  sometimes  tlie  e})ithelium 
assumed  the  form  of  papilla;  sf)ringing  from  the  gland  cavity,  and  some- 
times a  striking  i)alisado-likc  arrangement  of  long,  narrow,  and  closely- 
set  cylindrical  epithelium.      Apparently  without  connection  with  the 


MALIGNANT  DISEASES    OF   THE    UTERUS  733 

mucosa  there  were  lying  throughout  the  whole  muscular  layers  of  the 
uterus  islands  of  a  tissue  exactly  resembling  the  mucous  lining  in  struct- 
ure. .  .  .  These  islands  were  really  connected  by  long,  narrow,  glandu- 
lar tubules,  wliich  broke  through  the  muscular  layers,  and  then  formed 
gland-like  coils  of  tubes.  In  the  small  cysts  the  papillary  projections 
liave,  according  to  the  description,  exactly  the  histological  form  and 
appearance  of  the  "  mucous  polypi "  seen  at  the  os  externum  in  either 
young  or  old  women.  The  author  proceeds  to  remark  that  the  whole 
mode  of  extension  is  in  contrast  to  that  of  the  ordinary  form  of  cancer 
of  the  body,  which  we  designate  alveolar.  It  is  altogether  a  special  form. 
In  adenoma  the  cancerous  glands  in  a  loose  open  fashion  break  through 
the  neighbouring  tissues  ;  the  form  of  extension  is  almost  dendritic.  In 
alveolar  cancer,  on  the  other  hand,  the  process  is  hardly  ever  dilf use ;  it 
leaves  large  portions  of  the  uterus  intact,  and  invades  the  contiguous 
tissues  continuously  from  the  mucosa  outwards.  The  author  finally  calls 
attention,  as  others  have  done,  to  a  feature  which  is  more  or  less  charac- 
teristic of  the  rapid  growth  of  epithelial  elements  in  adenoma ;  namely, 
the  rapid  development  of  the  palisade-like  arrangement  of  a  long, 
narrow,  closely-planted  cylindrical  epithelium.  With  the  name  adenoma 
l)enignum  we  must  become  accustomed  to  associate  the  idea  of  a  tend- 
ency to  take  on  malignant  action,  so  that  the  epithet  "  benign  "  becomes 
merely  a  term  of  self-comfort  and  indecision. 

Landerer  refers  to  a  separate  cystic  space  in  the  uterine  wall  in 
advance  of  the  general  invasion  as  a  metastasis.  Cases  have  been  re- 
ported in  which  genuine  metastases  occurred  in  the  lungs  and  liver,  in 
which  recurrence,  as  carcinoma,  took  place  in  the  cicatrix  after  total 
extirpation  of  the  uterus,  and  in  which  the  disease  ran  a  much  more 
rapid  course  than  that  which  is  almost  characteristic. 

In  the  inchoate  state  of  our  scientific  observations  of  this  disease,  and 
the  consequent  unripe  condition  of  our  knowledge,  it  would  be  altogether 
premature  to  attempt  any  exposition  of  the  subject  under  the  usual  heads 
of  pathological  anatomy,  course  and  symptoms,  diagnosis,  and  so  forth. 
We  see  the  chief  points  in  the  cases  quoted :  the  usual  advanced  age  of 
the  patients,  the  insidious  beginning  and  chronic  course,  the  absence 
of  foetor  and  other  characters  of  the  discharge,  the  usual  occurrence  of 
luemorrhage,  and  later  the  development  of  the  symptoms  and  of  the 
general  condition  of  health  are  characteristic  of  cancer  of  the  body  of  the 
uterus. 

From  incidents  in  the  history  of  treatment  we  may  also  reflect,  not 
without  advantage,  on  the  fatuity  of  comforting  ourselves  with  a  jargon 
of  nomenclature,  such  as  senile  endometritis,  fungous  endometritis, 
diffuse  benign  adenoma,  or  even  endometritis  chronica  glandularis 
hyperplastica,  as  applied  to  post-climacteric  activity  in  the  uterus. 

All  activity  of  the  endometrium  in  post-climacteric  women  which  is 
not  completely  accounted  for  by  other  ascertainable  causes  should  be 
looked  upon  as  malignant.  When  so-called  soft  mucous  polypi  occur  they 
may  be  removed,  their  scat   of  origin  may  be  destroyed  by  operation, 


734  SYSTEM  OF  GYNECOLOGY 

and  then,  owing  to  the  chronicit}^  of  the  disease,  the  case  is  lost  sight  of 
and  the  disease  is  believed  to  be  cured.  The  disease  may  occasionally 
develop  before  the  menopause,  but  all  post-climacteric  polypus  or  fungus 
of  the  endometrium  of  the  body  of  the  xiterus  is  adenoma  malignura. 

VI.  Deciduoma  Malignum. — This  disease  of  the  uterus,  which  has 
received  much  attention  in  recent  years  from  German  and  French  gynae- 
cologists and  pathologists,  is  by  reason  of  its  rapidity  of  local  growth, 
and  tendency  to  metastases,  the  most  malignant  of  all  known  maladies. 
To  M.  Sanger  (43),  of  Leipzig,  is  due  the  credit  of  first  calling  attention 
to  this  disease,  to  which  he  applied  the  name  given  above.  He  main- 
tained that  the  tumour  described  by  him  was  malignant,  and  consisted 
of  decidual  or  placental  elements  so  characteristic  as  to  distinguish  them 
from  any  other  form  of  tumour  found  in  the  uterus.  Later  he  spoke  of 
it  (44)  as  "  an  entirely  new  type  of  decidual  tumour,"  which  had  been 
recognised  in  the  malignant  metastases  forming  deciduoma  or  decidual 
sarcoma.  In  1893  Sanger  (45)  published  his  observations  and  opinions 
in  a  more  complete  form,  including  a  review  and  criticism  of  the  cases 
published  meanwhile  by  other  gynaecologists.  He  then  gave  up  the  name 
"  deciduoma  malignum,"  and  adopted  ''  sarcoma  deciduo-cellulare,"  to 
indicate  his  view  of  the  origin  of  the  tumour.  Subsequent  controversy 
would  appear  to  suggest  that  this  change  was  rather  precipitate. 

Sanger's  own  case  is  given  in  detail  as  follows :  — 

A  woman  married  four  months,  in  consequence  of  an  accidental 
stumble  in  leaving  a  railway  carriage,  had  an  abortion  in  the  eighth 
week  of  pregnancy.  The  ovum  was  not  completely  expelled,  and  she 
suffered  from  profuse  haemorrhage  for  three  weeks.  In  the  fourth  week 
a  foul-smelling  discharge  from  the  uterus  began,  with  accompanying  high 
temperature.  When  Sanger  was  called  in  he  found  the  patient  very 
anaemic,  with  all  the  marks  of  retention  of  putrid  parts  of  the  ovum,  and  of 
septic  absorption.  The  uterus  was  cleared  of  its  contents  after  dilatation 
with  laminaria  tents ;  the  temperature  then  fell,  the  bleeding  and  foul 
discharge  also  ceased,  but  the  pulse  never  came  down  to  100.  The 
general  condition  of  the  patient  did  not  improve  much,  and  five  months 
elapsed  before  slie  could  leave  her  bod.  The  convalescence  was  hindei'ed 
by  a  diffuse  mass  of  parametritic  exudation  in  front  and  to  the  loft  of  the 
uterus.  This  gradually  disappeared  without  corresponding  iniproveinent 
in  the  patient's  health.  The  uterus  remained  large,  but  the  abdomen 
was  flat,  and  there  was  no  trace  of  peritonitis.  There  was  never  any 
purulent  discharge  from  the  pudenda.  Soon  the  patient  had  to  take 
to  V^ed  again,  owing  to  a  return  of  the  fever  and  pain  in  the  left  hypo- 
gastrium.  Then  there  appeared  in  the  right  iliac  fossa  a  tumour  about 
the  size  of  a  goose's  egg;  this  tumour  was  soft,  elastic,  and  tender  on 
pressure.  It  was  at  first  supposcMl  to  bo  an  absc-css,  resulting  from  septic 
infection  ;  and  the  enlargement  of  the  uterus,  which  was  now  distinct,  was 
attributed  to  the  same  cause.  The  patient  was  admitted  to  hospital,  and 
an  incision  was  made  into  the  swelling.    Instead,  however,  of  the  expected 


MALIGNANT  DISEASES    OF    THE    UTERUS 


735 


pus,  the  spongy,  fungous  substance  of  a  tumour  api)eared,  and  a  handful 
of  it  was  cleared  out  with  the  fingers  and  sharp  spoon.  At  the  bottom 
of  the  cavity  the  bone  was  found  to  be  denuded  of  periosteum.  Micro- 
scopic examination  showed -that  the  masses  consisted  of  round  cells  with 
large  nuclei,  together  with  a  small  amount  of  spindle  cells  and  blood- 
clot.  Tubercle  bacilli  were  not  found.  The  patient  was  transferred  t(j 
Professor  Thiersch  for  further  operation,  Ijut  owing  to  her  general  con- 
dition, with  new  symptoms  including  cough  and  dyspnoea,  nothing  was 
done.  The  uterus  increased  to  the  size  of  a  four  months'  pregnancy, 
while  the  patient  became  greatly  emaciated,  and  she  died  seven  months 
from  the  onset  of  the  symptoms  of  abortion.  The  post-mortem  examina- 
tion, Avhich  was  made  by  Professor  Birch-Hirschfeld,  gave  some  sur- 
prising results.  The  uterus  Avas  found  to  be  the  seat  of  several  tumours, 
which  were  at  first  regarded  as  sarcoma  teleangiectodes  ;  and  there  were 
metastases  in  the  lungs,  diaphragm,  ribs,  and  elsewhere.  The  uterine 
mucous  membrane  Avas  smooth  throughout;  and  this  point  is  of  the 
greatest  interest  in  comparing  Sanger's  case  Avith  others  subsequently 
published.  Microscopic  examination  led  Sanger  to  the  conclusion  that 
his  case  Avas  one  of  malignant  deciduoma  not  hitherto  described ;  and 
from  the  opinion  Avhich  he  formed  of  its  origin  in  the  cells  of  the  decid- 
ual connective  tissue  he  classed  it  as  a  form  of  sarcoma. 

Contributions  to  the  phenomena  and  pathology  of  the  ncAv  disease 
soon  began  to  appear.  The  first  case  Ave  find  in  Avhich  the  disease  Avas 
diagnosed  during  life,  and  an  attempt  made  to  cope  Avith  it,  is  that  of 
Gottschalk  (12). 

The  clinical  facts  show  that  hagmorrhage  began  in  February,  in  a  case 
of  abortion  at  two  months,  and  the  curette  and  tampon  Avere  repeatedly 
used  during  the  Avhole  summer  as  haemorrhage  recurred;  it  Avas  not 
until  the  10th  of  August  that  the  operation  of  extirpating  the  uterus  Avas 
carried  out  as  a  last  resource,  "  in  spite  of  the  deplorable  condition  of 
the  patient."  Gottschalk  formed  the  opinion  that  the  placental  villosi- 
ties  had  undergone  a  process  of  malignant  degeneration.  The  cellules 
of  the  serotina  had  become  infected  Avith  the  sarcomatous  virus ;  and  a 
foetal  tumour  had  been,  as  it  Avere,  injected  into  the  maternal  tissues, 
producing  destruction  of  the  uterine  wall. 

These  are  early  representative  incidents  in  a  discussion  Avhicli  has  been 
proceeding  for  several  years,  and  to  Avhich  many  addresses  and  Avritten 
papers  have  been  contributed.  Concerning  much  of  the  published  material 
it  is  not  too  harsh  to  describe  it  as  "  arid,"  with  a  French  revicAver,  Avho 
had  evidently  suffered  under  it.  The  most  recent  contribution  to  the 
literature  of  the  subject  of  deciduoma  malignum  appears  to  be  the  report 
of  the  proceedings  of  the  Berlin  (xyniecological  Society  ;  and  Ave  may 
noAvask  Avhether  any  facts  stand  clearly  and  definitely  out  after  the  cloud 
of  Avords  has  cleared  aAvay  ?  Is  there  anything  in  it  Avorth  our  knowing? 
The  answer  must  be  that  there  has  been  a  definite  addition  to  our  know- 
ledge, and  as  far  as  practical  gyntecology  is  concerned  the  matter  is  settled. 
The  controversy  among  the  pathologists  appears  to  be  only  well  begun. 


736  SYSTEM  OF  GYNECOLOGY 

Pathological  Anatomy. — The  characteristic  feature  which  gives  to 
deciduoma  maliguum  a  special  place  among  the  new  groAvths  is  the 
presence  of  giant  cells  grouped  in  a  particular  way,  and  endowed  with  a 
power  of  reproduction  which  is  almost  or  altogether  unique.  These  cells 
are  also  found  in  the  secondary  growths,  where  they  present  exactly  the 
same  appearance  and  relationships.  The  tumour  is  produced  by  an 
abnormal  proliferation  of  these  giant  cells  of  the  decidua ;  but  its  bulk 
is  also  largely  made  up  of  a  cellular  tissue  resembling  sarcoma,  and  the 
cells  of  this  class  are  found  around  the  tumour  invading  and  infiltrating 
the  normal  tissues  of  the  organ  affected.  The  giant  cells  have  been 
carefully  studied  in  their  forms,  grouping,  and  method  of  increase;  and 
have  been  divided  by  Nove-Josserand  and  Lacroix  into  three  categories, 
though  the  authors  admit  that  there  are  numerous  anomalous  and  inter- 
mediate forms.  The  presence  in  the  best  examples  of  deciduoma  malig- 
uum of  a  considerable  proportion  of  sarcoma-like  substance  has  led  to  the 
inclusion  of  cases  in  this  group  of  new  growths  which  really  belong  to 
pure  sarcoma ;  and  from  this  confusion  has  arisen  much  of  the  controversy. 

The  characteristic  structure  of  the  tumour  is  the  layer,  seen  on  sec- 
tion, which  lies  between  the  necrosed  tissue  lining  the  uterine  cavity 
and  the  genuine  uterine  substance  more  or  less  altered  by  the  reaction 
produced  by  invasion.  In  addition  to  its  special  cell  formation  this 
I)ortion  of  the  tumour  is  extremely  vascular ;  hence  the  profuse  haemor- 
rhages which  are  so  constantly  referred  to  in  the  clinical  history  of  each 
case.  It  is  here  that  in  some  cases  the  villous  arrangement  can  be 
observed,  which  in  appearance  suggests  the  chorionic  villi ;  hence  the 
division  of  the  cases  into  two  groups  by  Sanger,  and  the  name  chorio- 
deciduoma  malignum  proposed  by  Gottschalk.  The  dendritic  form  in 
this  malignant  disease  has  been  ascribed  to  a  myxomatous  degeneration 
of  the  villi,  largely  on  the  ground  that  the  genuine  deciduoma  malignum 
is  so  often  seen  after  hydatid  mole  pregnancy ;  but  several  competent 
pathologists,  who  have  carefully  examined  the  tumours  formed  after 
hydatid  mole,  have  failed  entirely  to  find  any  trace  of  the  villous 
arrangement. 

The  ultimate  facts  concerning  the  point  of  departure  of  these  growths 
have  given  rise  to  much  controversy,  and  are  by  no  means  settled. 

The  opinions  of  Marchand  (30)  have  been  received  with  the  greatest 
favour,  and  may  be  concisely  stated. 

a.  All  the  cases  are  essentially  of  the  same  nature,  although  they 
present  individual  differences  owing  to  varying  conditions  in  the  history 
of  their  development. 

h.  All  the  tumours  are  epithelial,  the  tissues  combining  in  their 
formation  being  (a)  the  syncytium,  that  is,  the  uterine  epithelial  layer 
of  the  chorion  ;  (ft)  the  elements  of  the  so-called  cellular  layer  (layer  of 
Langhans),  that  is,  the  ectodermal  epithelium  of  the  chori(m. 

c.  The  two  orders  of  elements  form  a  normal  constituent  of  the 
se rot  in  a. 

(I.  The    derivatives    from  the  syncytium  take  different  forms:   (a) 


MALIGNANT  DISEASES   OF   THE    UTERUS  'jyj 

very  large  cells  with  large  nuclei  rich  in  chromatine ;  (6)  protoplasmic 
masses  with  multiple  nuclei;  (c)  trabecular  and  retiform  multinuclear 
structures  which  are  surrounded  by  blood-spaces,  and  which  hold  the 
same  relation  to  these  as  the  syncytium  does  to  the  intravillous  spaces. 

e.  The  elements  of  the  cellular  layer  (of  the  ectoderm)  most  fre- 
quently occur  as  polyhedral  clear  cells  containing  glycogen.  They 
multiply  by  indirect  division  of  the  nuclei.  They  vary  in  size,  but  are 
usually  smaller  than  those  of  the  syncytium. 

/.  Hydatid  mole  pregnancy  favours  the  occurrence  of  malignant  neo- 
plasms, inasmuch  as  the  epithelial  elements  penetrate  the  serotina  more 
deeply  than  in  normal  pregnancy. 

g.  The  deeidua  cells,  properly  so-called,  do  not  participate  in  the 
formation  of  the  malignant  neoplasms,  or  only  in  a  very  small  degree  at 
the  primary  site  of  origin. 

h.  No  participation  of  the  connective  tissue  of  the  chorion  in  the 
formation  of  the  malignant  neoplasm  has  yet  been  demonstrated. 

i.  The  formation  of  metastases  from  these  tumours  proceeds  almost 
invariably  by  way  of  the  blood-vessels. 

Marchand  having  convinced  himself  that  these  malignant  tumours, 
designated  "deciduoma"  and  "sarcoma  deciduo-cellulare,"  are  really 
epithelial  growths,  proceeds  to  show  cause  why  he  should  not  adopt  the 
obvious  alternative  in  nomenclature,  and  call  them  carcinoma.  He  pro- 
poses, therefore,  the  term  "  serotinal  tumour  "  as  the  most  suitable. 

Marchand's  exposition  of  his  views  is  sufficiently  clear,  and  he 
appears  to  have  brought  some  sort  of  order  into  the  chaos  of  opinion 
existing  among  his  colleagues.  A  timely  contribution  by  him  (29)  to  the 
structure  and  pathology  of  hydatid  mole  has  also  done  much  to  clear  up 
the  confusion. 

Course  and  Symptoms. — When  we  come  to  consider  the  symptoms 
and  course  in  a  typical  case  of  the  disease  in  question  we  are  on  surer 
ground.  It  is  a  disease  sui  generis.  All  experience  proves  that  cancer 
of  the  body  of  the  uterus  is  a  disease  of  elderly  women.  The  average 
age  in  twenty-six  cases  of  deciduoma  malignum  was  33-7  years. 

The  first  symptom  is  haemorrhage  coming  on  soon  after  parturition  at 
full  term,  or  after  interruption  of  pregnancy,  especially  of  hydatid  mole 
pregnancy.  Almost  invariably  the  htemorrhage  has  been  attributed 
to  retention  of  products  of  conception,  a  natural  enough  mistake  until 
after  the  first  curetting,  not  afterwards.  Rarely  as  the  disease  occurs, 
it  should  always  be  suspected  as  the  cause  of  hai'morrhage  after  the 
apparently  complete  expulsion  of  a  hydatid  mole.  This  cause  of  abortion 
was  the  immediately  preceding  fact  in  about  half  of  all  the  cases  reported. 
In  one  case,  at  least,  it  was  only  the  facts  ascertained  by  the  microscopic 
examination  of  an  extirpated  uterus  that  led  to  the  inquiries  which  com- 
pleted the  clinical  history  of  hydatid  mole  pregnancy  as  immediately 
preceding  the  appearance  of  symptoms.  Xove-Josserand  and  Lacroix 
have  endeavoured  to  prove  that  the  lu^morrhage  jiresents  certain  constant 
characteristics.    It  is  certainly  more  profuse  than  the  luemorrhage  usually 

3b 


738  SYSTEM  OF  GYNECOLOGY 

occurring  after  abortion ;  the  patients  become  excessively  ansemic,  and 
in  some  of  the  cases  reported  death  was  mainly  due  to  the  loss  of  blood. 

The  nest  symptom  which  appears  comparatively  early  is  profuse 
foetid  discharge.  It  is  a  dirty-water,  sanguinolent  fluid,  which  persists 
even  after  haemorrhage  has  been  temporarily  suppressed  by  the  use  of 
the  curette  and  other  measures. 

Deterioration  of  the  general  health  now  comes  on  rapidly ;  the  patient 
becomes  cachectic  looking,  can  take  no  food,  and  soon  loses  flesh  to  a 
serious  extent.  She  has  all  the  appearance  of  suffering  from  malignant 
or  advanced  wasting  organic  disease. 

Physical  examination  usually  reveals  the  fact  that  the  uterus  is  larger 
than  normal  and  freely  movable.  In  more  advanced  or  neglected  cases 
bimanual  examination  may  bring  out  the  fact  that  there  are  irregularities 
about  the  uterus  or  in  the  vagina  due  to.  secondary  growths.  Dilata- 
tion of  the  uterine  canal  will  enable  the  medical  attendant  to  ascertain 
the  presence  in  the  uterus  of  soft  friable  masses  of  vegetating  tissue, 
like  placental  debris,  mixed  with  more  or  less  changed  blood-clot.  The 
tumour  may  be  diffuse,  but  it  is  usually  distinctly  localised  and  attached 
to  the  wall  of  the  body  of  the  uterus.  This  fact  distinguishes  the  case 
from  one  of  retained  shreds  of  placenta,  membrane  or  blood-clot.  Some 
have  described  the  site  of  attachment  after  the  removal  of  the  tumour 
as  giving  the  impression  that  the  uterine  wall  was  almost  or  altogether 
perforated.  This  appears  to  prove  invasion  of  the  wall  of  the  uterus  by 
the  neoplasm. 

When  the  case  has  become  fairly  advanced  metastases  invariably 
occur,  and  give  rise  to  symptoms  connected  with  the  organ  or  organs  so 
affected.  In  most  cases  lung  symptoms  arose,  sometimes  in  such  a  marked 
form  as  to  suggest  pulmonary  tubercle.  In  Gottschalk's  case  the  lung 
symptoms  were  urgent  before  operation;  but  they  afterwards  so  far 
improved  as  to  suggest  that  they  must  have  been  sympathetic.  The 
patient,  however,  died  in  a  few  months  from  widely  diffused  secondary 
growths. 

In  the  course  of  the  undecided  treatment  described  in  some  cases  local 
inflammation  followed  by  septicaBuiic  symptoms  was  observed,  so  that 
it  must  have  been  difficult  or  impossible  to  say  whether  the  patient  died 
from  the  original  disease  or  from  septicaemia. 

An  account  of  the  clinical  characters  of  such  a  disease  as  deciduoma 
malignum  with  its  rare  occurrence  and  recent  history  would  not  be  com- 
plete without  some  illustrative  cases. 

Mfuige's  case  (31),  from  the  University  Hospital  for  Women  of  Leipzig, 
is  fairly  illustrative  of  the  disease  under  consideration,  and  from  the  clini- 
cal point  of  view  it  is  instructive.  In  December  1892,  admission  to  the 
hospital  of  patient,  ait.  85,  pregnant  six  months,  with  uterine  haemorrhage ; 
thi  rteen  days  after  admission,  expulsion  of  hydatid  mole  with  assistance  of 
manipulations  of  uterus  ;  shreds  of  tumour  left  in  uterus,  causing  hannor- 
rhage ;  rise  of  tem]jerature  to  10.'}-5° ;  no  treatment  or  int(!rferen(!e.  Eight 
daysafterabortion  examination  revealed  "lochiometra";  inscirtion  of  index 


MALIGNANT  DISEASES   OF  THE    UTERUS  739 

finger  into  cervix  to  effect  relief.  On  8th  January  patient  left  hospital. 
In  May  an  attack  of  haemorrhage  from  the  uterus  occun-ed,  for  which  the 
patient  was  treated  at  home  by  curetting.  On  7th  July  admission  again 
to  hospital  on  account  of  pain  and  haemorrhage.  Dilation  by  tents  and 
removal  of  nodules  of  tumour  with  linger  and  curette.  Material  thus 
obtained  thrown  away  without  examination.  Rise  of  temperature  to 
104°.  Patient  sent  home  IGth  July.  Three  weeks  later  patient  again 
brought  into  hospital  after  almost  fatally  profuse  haemorrhage.  Xext 
day,  after  dilatation  by  tents,  removal  by  sharp  curette  of  large  masses 
of  placenta-like  substance  from  body  of  uterus.  Patient  extremely 
angemic.  Temperature  immediately  after  operation  over  104°,  after 
which  rapid  fall.  Nodules  removed  subjected  to  careful  examination. 
After  delay  of  another  week  total  extirpation  resolved  on  and  carried 
out.  During  operation  the  author  was  "very  disagreeably  surprised'' 
to  find  secondary  nodules  in  the  vagina.  Unsatisfactory  recovery  ; 
rapid  recurrence ;  death  of  patient  six  months  after  operation. 

The  special  feature  of  this  next  case  (56)  was  the  length  of  time 
which  elapsed  between  the  mole  abortion  and  the  marked  symptoms 
of  malignant  disease.  The  abortion  occurred  at  about  seven  months, 
in  May  1891 ;  expulsion  of  hydatid  mole,  described  by  practitioner  in 
attendance  as  amounting  to  from  three  to  four  quarts.  Haemorrhage  in 
the  summer  of  1891,  but  not  regular  menstruation.  In  February  1892 
foul-smelling  discharge.  In  INIay  1892,  when  patient  came  under  Lohlein's 
observation,  there  was  a  foul,  blood-stained  watery  discharge ;  os  uteri 
open,  with  irregular  friable  masses  projecting.  The  tumour  masses  were 
removed,  and  the  patient  improved.  After  six  weeks,  return  of  symptoms 
with  fever.  Total  extirpation  of  the  uterus  after  removal  of  "  polypus  " ; 
good  recovery.  Patient  reported  well  five  months  later.  Examination 
of  uterus  and  tumour  showed  sarcoma  structure  with  distributed  nodules 
containing  large  "  decidua-like  cells."  Lohlein  considers  the  tumour 
exceptionally  benign,  but  still  within  the  category  of  sarcoma  of  the 
uterus,  with  a  causal  relationship  to  hydatid  mole  pregnanc3^ 
.  In  the  following  contribution  by  Klein  to  the  history  of  malignant 
tumours  of  the  decidua  from  the  Eoyal  University  Hospital  for  Women, 
of  Munich,  the  author  gives  an  account  of  Avhat  he  considers  to  be  a  case 
of  decidual  sarcoma  after  hydatid  mole  pregnancy.  The  interest  of  the 
case,  except  as  a  warning,  lies  largely  in  the  post-mortem  examination 
and  the  material  obtained  from  it,  which  was  subjected  to  careful  in- 
vestigation. The  patient  was  a  married  woman  set.  27.  She  began  to 
bleed  in  the  last  week  of  January  1893.  The  fundus  of  the  uterus  was 
then  as  high  as  the  umbilicus.  Haemorrhage  from  the  uterus  continued 
to  12th  March,  although  tampons  Avere  used  almost  daily,  and  a  hydatid 
mole  was  then  expelled.  Haemorrhage  and  pain  frequently  recurred. 
After  nearly  two  months  more  the  uterus  was  curetted.  Some  improve- 
ment for  a  short  time,  then  relapse,  with  complications.  It  was  not  till 
November  that  the  ])atient  was  sent  in  a  dying  state  into  the  hospital 
by  the  practitioner  who  had  attended  from  the  beginning  of  tlie  illness. 


740 


SYSTEM   OF   GYN.-ECOLOGY 


The  disease  was  found  to  have  spread  to  the  vagina  and  parametrium, 
and  there  -were  small  metastatic  areas  elsewhere. 

One  of  the  best  reported  and  in  other  respects  most  satisfactory 
cases  recorded  is  that  of  iSTove-Josserand  and  Lacroix,  of  Lyons,  already 
referred  to. 

The  case,  shortly  stated,  was  as  follows :  —  Married  woman,  eetat  24, 
became  pregnant  the  third  time  in  1892.  In  March  patient's  abdomen 
was  about  the  normal  size  at  full  term.  Haemorrhage  for  from  six  to 
eight  weeks,  then  spontaneous  expulsion  of  enormous  hydatid  mole. 
Patient  well  for  a  month,  then  recurrence  of  haemorrhage  every  few 
days.  Sent  into  hospital,  under  Fochier,  5th  June.  Examination  after 
dilatation  and  removal  of  some  friable  debris  ;  temporary  cessation  of 
haemorrhage.  Ee-admission  10th  July.  Patient  then  losing  blood  from 
uterus  profusely  ;  had  become  exsanguine  and  so  weak  that  she  could 
not  leave  her  bed;  evening  rise  of  temperature.  Vaginal  hysterectomy 
12th  July;  recovery  excellent.  Patient  reported  well  three  months 
later. 

Histological  examination  gave  results  similar  to  those  already  pub- 
lished, with  additional,  but  not  essentially  dilferent  details.  In  the 
"clinical  study"  of  the  disease  the  authors  direct  particular  attention 
to  certain  peculiarities  about  the  haemorrhages,  Avhich  are  intermittent, 
sudden,  and  profuse,  endangering  the  life  of  the  patient;  and  a  metror- 
rhagic  or  serous  discharge  of  small  amount  frequently  occurs  during  the 
whole  of  the  intervals.  Tamponment  only  temporarily  arrests  the  bleed- 
ing. Then  the  discharge  becomes  offensive,  indicating  infection  of  the 
uterine  cavity.  A  rapid  alteration  in  the  condition  of  the  patient  takes 
place ;  loss  of  flesh,  weakness,  pallor,  and  anorexia  supervene.  Physical 
examination  shows  the  uterus  to  be  more  or  less  enlarged,  and  explora- 
tion of  the  cavity  at  an  early  stage  reveals  the  presence  of  a  localised 
friable  tumour.  If  this  tumour  be  removed  it  is  rapidly  reproduced. 
There  may  be  room  for  difference  of  opinion  as  to  the  details  of  the 
examination  and  the  preparatory  treatment  recommended  by  Fochier  ; 
but  the  main  point,  prompt  total  extirpation,  a  measure  which  must 
commend  itself  to  all  gynaecologists,  is  strongly  enforced. 

Diagnosis.  —  Considering  the  marked  character  of  the  disease 
brought  out  in  the  cases  recorded  it  will  be  obvious  that  there  should 
now  be  little  difficulty  in  any  case  which  may  occur.  The  main  facts 
to  keep  in  mind  are  :  — 

1.  The  history  of  recent  parturition  probably  following  interrup- 
tion of  pregnancy,  especially  of  hydatid  mole  pregnancy.  The  exist- 
ence of  decidua  in  the  uterus  is  a  condition  essential  to  the  development 
of  deciduoma  malignum. 

2.  The  symptoms  of  profuse  haemorrhage  which  have  recurred 
again  and  again  to  such  an  extent  as  to  have  made  the  patient  ex- 
tremely anaemic. 

3.  The  occurrence  of  a  foul-smelling,  thin,  watery,  or  sanguineous 
discharge,  which  continues  in  spite  of  such  curetting  as  may  have  put  an 


MALIGNANT  DISEASES    OF    THE    UTERUS  741 

end  to  the  haemorrhage  for  the  time  being  ;  anaemia,  with  loss  of  flesh 
and  deterioration  of  the  general  health,  with  a  rapidity  and  to  an  extent 
beyond  that  which  might  be  expected  from  the  symptoms  and  the  dura- 
tion of  the  disease. 

4.  Such  symptoms  demand  closer  investigation,  and  it  becomes 
necessary  to  explore  the  uterus ;  it  has  become  more  or  less  enlarged, 
and  when  the  uterine  cavity  has  been  dilated  to  admit  the  index  finger, 
friable  bleeding  masses  can  be  extracted  and  put  under  the  microscope 
for  differential  diagnosis.  The  diagnosis,  however,  can  be  completely 
established  by  clinical  facts  alone.  When  the  uterus  has  been  explored, 
and  the  curette  used  once  for  all,  if  there  be  a  recurrence  of  haemorrhage 
and  foul  discharge,  there  is  also  recurrence  of  a  malignant  neoplasm. 

It  is  easy  to  criticise  the  treatment  of  some  of  the  early  cases  by  men 
who  were  placed  in  an  extremely  difficult  position  in  dealing  with  a 
rapidly  fatal  malady  which  they  could  not  diagnose  without  the  guid- 
ance of  previous  experience  ;  and  there  can  be  no  doubt  that  the  repeated 
use  of  the  curette  in  order  to  bring  away  debris  of  a  recurring  malig- 
nant growth  could  only  hasten  the  occurrence  of  metastases.  But  the 
mistakes  appear  to  have  been  honestly  recorded,  and  the  experience  all 
points  to  this,  that  the  patient's  life  depends  upon  prompt  diagnosis  and 
prom]jt  definite  treatment. 

Prognosis.  —  The  disease  is  rapidly  fatal.  The  prognosis  as  to  length 
of  life  depends  upon  the  results  of  surgical  treatment,  and  these  results 
depend  in  their  turn  upon  certain  circumstances  which  have  to  be 
weighed :  — 

1.  There  is  the  immediate  danger  from  the  operation  of  hysterectomy. 

2.  The  danger  that  secondary  invasion  has  somewhere  occurred,  in 
which  case  all  surgical  measures  will  be  in  vain. 

The  development  of  metastases  appears  to  depend  upon  —  (a)  the 
degree  of  malignancy  in  the  different  cases ;  (&)  the  lapse  of  time  since 
the  first  symptoms  appeared  ;  (c)  the  amount  of  stimulation  or  wounding 
of  the  uterus  resulting  from  manipidations  intended  for  treatment. 

There  appears  to  be  nothing  in  the  previous  individual  health  or 
family  history  of  the  patients  to  be  considered.  They  are  usually  young 
and  apparently  healthy  Avomen  Avith  every  expectation  of  life.  The 
disease  has  some  analogy  to  puerperal  septicaemia,  which  be3-ond  a  cer- 
tain stage  is  absolutely  fatal  unless  a  definite  course  of  treatment  be 
pursued ;  and  fatal  even  in  this  case  when  far  advanced. 

Treatment.  —  All  experience  points  definitely  to  one  method  of  treat- 
ment and  to  no  other  ;  that  is,  total  hysterectomy  per  vaginam,  with  the 
removal  of  as  much  of  the  ovaries,  tubes,  and  broad  ligaments  as  can  be 
reached  without  producing  undue  danger  of  shock. 

Some  recorded  cases  warn  us  against  indecision  and  delay.  AVe  have 
seen  how  to  arrive  at  a  diagnosis :  as  soon  as  the  diagnosis  is  settled  on 
clinical  grounds  the  operation  should  be  carried  out.  It  is  painfid  to  read 
of  ]iatient  and  doctors  waiting  for  the  pathologist's  report  while  the 
clinical  facts  point  with  moral  certainty  to  the  diagnosis,  and  while  the 


742  SYSTEM  OF  GYNECOLOGY 

disease  is  rapidly  developing  about  the  uterus,  and  perhaps  also  sending 
its  elements  of  reproduction  to  distant  parts  of  the  body. 

Several  cases  are  reported  which  warn  us  against  the  use  of  the  tampon 
to  arrest  hcemorrhage  in  this  disease ;  and  against  the  repeated  scraping 
of  the  cavity  of  the  uterus  even  after  the  discharge  has  become  septic 
and  the  neoplasm  is  recurring.  Bacon  reports  a  case  in  which  the  plug 
was  used  repeatedly  over  a  period  of  many  weeks  to  arrest  haemorrhage 
after  a  hydatid  mole  pregnancy ;  the  curette  was  used  six  months  after 
the  symptoms  appeared,  and  the  patient  died  nine  days  after  the  opera- 
tion. The  post-mortem  diagnosis  suggests  a  great  deal.  It  was  as 
follows :  "  Deciduoma  of  the  right  broad  ligament  and  of  the  lungs ; 
endometritis  and  suppurative  salpingitis;  diffuse  purulent  peritonitis  and 
empyema  (bilateral) ;  "  with  other  more  general  disorders. 

Such  misfortunes  and  failures  in  treatment  as  are  contained  in  the 
clinical  records  of  this  disease  Avere  inevitable  in  the  case  of  the  pioneers 
who  had  to  grope  on  without  the  light  of  previous  experience  of  so 
mysterious  and  terrible  a  malady  as  deciduoma  malignum.  They  have, 
however,  the  satisfaction  of  knowing  that  they  have  placed  the  medical 
profession  under  a  debt  of  gratitude  by  the  faithfully  detailed  and  honest 
accounts  of  their  cases  published  for  the  guidance  of  others.  Those  of 
us  to  whom  their  records  are  opeuAvill  be  without  their  excuse  if  we  fail 
to  diagnose  with  precision,  and  to  treat  promptly  and  effectively  any 
cases  which  may  henceforth  come  into  our  hands. 

W.  J.  Sinclair. 


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PLASTIC    GYNAECOLOGICAL    OPERATIONS  743 

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(Jeiitralblatt  fUr  Gyndk.  181)3.  —  28.  Mangiagalli.  "  Risultate  prossiiui  e  remoti  della 
isterectomia  vaginale  per  Carciuoua,"  Annali  di  Ostetricia  e  Ginecohgia,  November 
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Gyndk.  Bd.  xxxii.  H.  3,  1895.  —  30.  Ibid.  "Ueber  die  so-genannten  '  decidualen ' 
Geschwiilste,  etc."  Monat.  f.  Gebuvt.  und  Gyndk.  Bd.  i.  H.  5,  G,  1895.  —  31.  Menge. 
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1892.  —  34.  Pick.  "  Zur  Histogenese  and  Klassilication  der  Ciebairmutter  sarkome," 
Arch.  f.  Gyndk.  Bd.  xxi.  p.  24  ;  and  Whitridge  Williams,  "Contributions  to  the 
Histology  and  Histogenesis  of  Sarcoma  of  the  Uterus,"  Amer.  Journ.  of  Obst.  vol.  xxix. 
J).  721.  —  35.  Pick.  "Zur  Histogenese  und  Klassitication  der  Gebarmutter,"  Arch.  f. 
Gyndk.  Bd.  xlviii.  1894. — 3(!.  Picor.  Les  grands  proces-'ius  morbides,  1878. — 37.  Quain's 
Anatoyny,  vol.  iii.  part  iv.  p.  2G().  —  38.  Richelot.  Archives  generales  de  midecine, 
1892.  —  39.  Ibid.  "  Derniers  resultats  de  riiysterectomie  vaginale,"  Annales  de 
gynicologie,  Dec.  1895. — 40.  Ruge  and  Veit.  Zeitschrift  fiir  Geburt.  und  Gyndk.  Bd. 
iv.  1881.  —  41.  Ruge.  "Das  Mikroskop  in  der  Gynakologie  und  die  Diagnostik," 
Zp.itschrift  fiir  Geb.  und  Gyndk.  Bd.  20, 1890.  —  42.  Ibid.  "  Ueber  Adenom  des  Uterus," 
Vei-handlungen  der  deutschen  Gesellschaft,  1888.  —  43.  Sanger.  Centralblatt  fiir  Gyndk. 
1889. — 44.  Ibid.  "  Ueber  Deciduome,"  Verhandhmg.  der  deutschen  Gesellschaft,  1892. 
— 45.  Ibid.  "  Ueber  Sarcoma  uteri  deciduo-cellulare  und  andere  deciduale  Geschwiilste," 
Arch  iv  fiir  Gyndk.  Bd.  xliv.  1894.  —  4!!.  Schmidt.  Centralblatt  fiir  Gyndk.  No.  43, 
1895. — 47.  ScHULTZ.  "Des  injections  intraparenchymateuses  d'Alcohol  dans  le  traite- 
ment  du  cancer  inoperable  ute'rin,"  Nouv.  Arch,  d'obstet.  et  de  Gyn.  No.  10,  1894. — 48. 
Simpson.  Clinical  Lectures  on  the  Diseases  of  Women,  1872. —49.  Spiegelderg. 
"  Casuistische  Mittheilungen  zu  den  Sarcomen  des  Uterus,"  Arch.  f.  Gyndk.  Bd.  iv. 
1872. — 50.  Terrier  and  Hartman.  "Immediate  and  Remote  Results  of  Vaginal 
Hysterectomy  for  Cancer,"  Revue  de  Chirurgie,  1892.  —  51.  Theilhaber.  "  Die  Behand- 
lung  des  Uteruscarcinoms  in  der  Schwangerschaft  und  bei  der  Geburt."  Arch,  fiir  Gyndk. 
Bd.  xlvii.  1894. — 52.  Thornton,  J.  Knowsley.  Address  on  the  Early  Diagnosis  of 
Mitlign'int  Disease  of  the  Uterus,  Brit.  Med.  Assoc.  London,  July  1895. — 53.  VfLLiET. 
"Ueber  die  palliative  Behandlung  des  Uteruscarcinoms  mit  Alkoholinjektionen,"  Cen- 
traiblatt  fiir  Gyndk.  No.  34,  1895.  —  54.   Wells,  Sir  Spencer.     Morton  Lectures,  1888. 

—  .55.  Williams,  Sir  John.    Cancer  of  the  Uterus. — 5(5.  Winckel.    Diseases  of  Women. 

—  57.  Winter.  "  Ueberdie  Recidive  des  Uterus  Krebses,"  Verhandlungen  der  deutschen 
Gesellschaft  fiir  Gyndkologie,  1893.  — 58.  Ibid.  "  Ueber  die  Schroeder'sche  Supravaginale 
Amputation  bei  Portiocarcinom,"  Zeitschrift  fiir  Geburt.  und  Gyndk.  Bd.  xxii.  H.  1, 
1891.  —  59.   Zeitschrift  fiir  Geb.  und  Gyndk.  Bd.  xxxiii. 

W.  J.  s. 


PLASTIC   GYNECOLOGICAL   OPERATIONS 

The  following  lines  will  not  contain  a  history  of  plastic  gynascic  opera- 
tions. It  appeared  to  me  better  to  describe  the  methods  adopted  in 
modern  gynaecology^,  than  to  recapitulate  all  the  procedures  recom- 
mended by  the  many  writers  of  the  past. 

Plastic  operations  in  gynaecology  may  be  conveniently  considered 
under  five  headinsrs  :  — 


744  SYSTEM  OF  GYNECOLOGY 

A.  Those  for  injaries  and  lacerations  of  the  pelvic  floor,  due  directly 

to  the  process  of  parturition. 

B.  Those  for  displacements  of  the  pelvic  floor,  including  prolapsus 

uteri,  cystocele,  urethrocele,  rectocele,  and  vaginal  enterocele. 

C.  Those  for  laceration  of  the  cervix,  the  result  of  parturition. 

D.  Those  for  certain  cervical  deformities  and  inflammations. 

E.  Those  for  repair  of  fistulous  openings  between  the  bladder  or 

intestine  and  other  viscera. 


A.     OPERATIONS    FOR    INJURIES     TO     THE     PELVIC     FLOOR     DIRECTLY    DUE 

TO    PARTURITION 

The  anatomy  of  the  pelvic  floor  may  with  advantage  be  given  in  a 
few  introductory  words.  This  is  composed  from  within  outwards  of 
(1)  a  pair  of  broad  and  thin  muscles  (the  levatores  ani),  which  are  the 
chief  means  of  support  of  the  pelvic  viscera;  (2)  an  arrangement  of 
fasciae  and  muscles  (more  superficially  situated),  the  components  of 
which  act  as  accessories. 

1.  The  levatores  ani,  with  the  coccygei  muscles,  form  the  true  pelvic 
diaphragm  :  each  levator  ani  arises  from  the  pubes,  the  white  line  of 
pelvic  fascia,  and  the  ischiatic  spine,  and  sweeping  downwards,  forwards, 
and  inwards,  by  its  anterior  fibres  becomes  attached,  from  before  back- 
wards, to  the  lower  portion  of  the  vagina,  aiding  in  forming  the  lateral 
sulci ;  by  its  middle  fibres  to  the  rectum,  blending  with  the  internal 
sphincter ;  and  by  its  posterior  fibres  to  its  fellow  of  the  opposite  side : 
the  coccygei  may  be  said  to  complete  this  pelvic  diaphragm  in  its 
posterior  portion.  One  of  the  chief  functions  of  this  musculature  is  to 
elevate  the  vagina  and  rectum,  and  to  preserve  the  slit-like  form  with 
bilateral  sulci  which  the  former  presents  on  transverse  section.  By  the 
vaginal  sulcus  is  meant  the  depression  between  the  centre  and  side  of 
the  vagina  which  produces  a  kind  of  groove  on  each  side. 

2.  The  most  external  covering  of  the  pelvic  floor  is  a  layer  of  super- 
ficial fascia,  itself  a  continuation  of  the  general  body  fascia;  beneath  this 
is  a  deeper  layer,  and,  finally,  there  is  the  so-called  triangular  ligament 
which  consists  of  an  anterior  and  posterior  lamina  filling  in  the  pubic 
arch.  Between  the  deeper  layer  of  the  superficial  fascia  and  the  ante- 
rior lamina  of  the  triangular  ligament  three  important  pairs  of  muscles 
are  found:  (a)  The  transversus  perinei.  (/3)  The  bulbo-cavernosus. 
(y)    The  erector  clitoridis. 

The  perineum  until  recently  was  considered  as  a  thick  wedge-shaped 
body,  partly  muscular,  partly  tendinous,  lying  between  the  vagina  in 
front  and  the  rectum  behind;  and  materially  aiding  in  the  support  of 
the  uterus :  we  now  more  accurately  regard  it  as  a  movable  centre  of 
attachment  for  the  transversus  perinei,  the  s])hincter  and  levator  ani, 
and  the  pelvic  fascia;  as  well  as  for  the  lower  portion  of  the  rectum  and 
vagina.     Thus  the  levator  ani  muscle,  with  the  pelvic  fascia,  forms  the 


PLASTIC   GYNALCOLOGICAL    OPERATIONS  745 

true  pelvic  floor  on  which  the  viscera  rest,  and  through  which  the  rectum 
and  vagina  find  their  exit. 

The  pelvic  floor  consists  of  two  "  segments  "  —  an  anterior  or  pubic 
and  a  posterior  or  sacral  —  separated  by  the  vaginal  slit  or  cleft ;  the 
pubic  portion  is  slightly  drawn  up,  or  remains  stationary  during  labour ; 
while  the  sacral  is  pressed  down  and  stretched  during  the  passage  of  the 
foetal  head  through  the  vulval  orifice  :  hence  it  is  that  practically  all  the 
lacerations  of  the  pelvic  floor  requiring  repair  are  confined  to  the  latter 
segment.  These  injuries  are  treated  by  certain  operative  procedures 
which  may  be  immediate  (that  is,  at  the  time  of  labour)  or  remote  (that 
is,  at  some  variable  time  after  the  accident,  not  earlier  than  eight  weeks) ; 
this  paper  is  devoted  only  to  a  consideration  of  the  "  remote  "  operations, 
as  the  "  immediate  "  belong  to  the  department  of  obstetrics. 

The  lacerations  of  the  pelvic  floor  fall  into  three  classes  :  — 

i.  Partial  Rapture  of  the  Perineum.  —  This  consists  of  a  median  tear 
through  the  transversus  perinei  and  bulbo-cavernosus  muscles,  and  the 
superficial  fascia  up  to,  but  not  into  the  sphincter  ani.  It  is  a  frequent 
result  of  the  passage  of  the  vertex  through  the  pelvic  outlet  in  first 
labours.  As  a  rule  it  is  productive  of  no  bad  symptoms,  but  occasionally 
gives  rise  to  a  feeling  of  descent  of  the  pelvic  viscera,  to  entrance  of  air 
into  the  vagina,  and  other  sensations  of  a  less  definite  nature.  Neither 
prolapsus  uteri  nor  gaping  of  the  vaginal  orifice  occurs  as  a  result  of  this 
accident. 

On  inspecting  such  parts  in  a  Avoman,  in  the  dorsal  decubitus,  who 
has  been  confined  a  sufiiciently  long  time  for  complete  cicatrisation  to 
have  taken  place,  it  will  be  noticed  that  the  vulval  outlet  is  somewhat 
prolonged  backwards,  but  is  not  patidous ;  upon  separating  the  labia,  a 
kidney-shaped  surface  covered  by  shining  mucous  membrane  (cicatricial 
tissue),  paler  than  usual  and  without  rugae,  will  be  seen.  The  sites  of 
the  torn  ends  of  the  transversus  perinei  and  bulbo-cavernosus  cannot,  of 
course,  be  detected.  On  being  told  to  bear  down  there  should  be  no 
more  than  an  ordinary  descent  of  the  uterus  and  vaginal  walls,  and  the 
sphincter  will  be  found  intact.  The  lateral  vaginal  sulci  will  be  present 
and,  on  passing  the  finger  into  each,  the  supporting  band  of  fibres  of  the 
levator  ani  may  be  distinctly  made  out.  The  sacral  segment  will  be  in 
apposition  to  the  pubic,  as  is  indicated  by  the  close  application  of  the 
anterior  to  the  posterior  vaginal  walls. 

ii.  Complete  Rupture  of  the  Perineum.  —  This  is  a  tear,  usually 
median,  through  the  perineum  and  internal  sphincter  ani.  The  patient 
suffering  from  this  distressing  condition  has  more  or  less  complete  incon- 
tinence of  faeces  and  flatus,  painful  sitting-doAvn,  and  not  infrequentl_y 
dyspareunia.  The  appearance  of  the  parts  after  cicatrisation  is  some- 
what as  follows  :  the  anus  is  represented  by  an  opening,  the  shape  of  an 
isosceles  triangle ;  the  base  of  this  triangle  is  formed  by  a  concave 
corrugated  surface  —  the  posterior  margin  of  the  anus  ;  the  sides  are  the 
edges  of  the  torn  recto-vaginal  septum.  The  sphincter  ani  being  com- 
pletely torn  through,  the  ends  have  retracted,  wrinkling  the  skin  between 


746 


SYSTEM   OF  GYNECOLOGY 


Fig.  154. — Compilete  rupture  of  the  perineum 
and  the  lower  portion  of  the  recto-vafjinal 
septum.  The  anterior  vag-inal  wall  re- 
tracted by  speoulum.  A  band  of  cica- 
tricial tissue  passes  obliquely  across  the 
cleft.     (After  Pozzi.) 


them ;  their  site  is  indicated  by  a  small,  almost  circular,  depression  upon 
each  buttock  (^Fig.  154).     The  mucous  membrane  of  the  rectum  is  red, 

inflamed,  and  prolapsed  or  everted ;  it 
bleeds  easily  when  touched,  and  se- 
cretes tenacious  mucus.  On  introduc- 
tion of  the  finger  into  the  rectum  there 
is  a  want  of  grip,  and  the  edges  of  the 
torn  recto-vaginal  septum  are  more 
clearly  defined.  The  anterior  and  pos- 
terior vaginal  walls  are  in  apposition, 
and  the  lateral  sulci  intact,  as  in  the 
former  case. 

iii.  Lacerations  of  the  Pelvic  Floor 
Proper. —  These  injuries  are  usually  uni- 
or  bilateral,  and  submucous,  being  pro- 
duced by  a  tearing  through  of  the  fibres 
of  the  levator  ani,  especially  of  those 
attached  to  the  vagina,  rectum,  and 
pelvic  fascia.  It  is  only  after  the 
patient  begins  to  get  about  that  the 
results  of  these  lacerations  are  noticed. 
If  the  attachments  of  the  levator  to 
the  rectum  and  vaginal  sulci  be  torn  through,  the  sacral  segment 
is  dragged  backwards  towards  the  coccyx ;  the  vulval  orifice  becomes 
elongated  antero-posteriorly ;  the  vaginal  walls  are  everted,  and  the 
vulval  outlet  patulous  —  the  latter  condition  being  recognised  in  ad- 
dition by  the  flatness  of  the  crease  between  the  buttocks,  anterior  to 
the  anus ;  and  the  recto-vaginal 
wall,  instead  of  being  concave,  be- 
comes convex  and  protuberant,  so 
as  to  produce  a  rectocele.  The  fin- 
ger inserted  into  the  vagina  will  fail 
to  detect  the  attachment  of  the  le- 
vatores  ani  to  the  lateral  borders  of 
the  lower  portions  of  the  vagina; 
it  is  probable  that  the  fibres  of  the 
levator  ani  attached  to  the  left  vagi- 
nal sulcus  are  those  most  usually 
torn  througli,  owing  to  the  frequency 
of  the  first  position  of  the  vertex. 

Typical  inst-ances  of  classes  i., 
ii.,  and  iii.  are  very  frequent,  but  it  must  be  l^orne  in  mind  that  it  is 
very  common  to  meet  with  cases  in  which  complete  perineal  laceration 
is  combined  with  lateral  rents  of  the  levator  ani :  in  such  cases  the 
physical  signs  would  present  a  compound  of  those  depicted  under  class 
ii.  and  f;lass  iii. 

It  will  be  more  convenient  to  consider  together  the  plastic  operations 


Fig.  155.  —  Relations  of  levator  ani  to  the  rectum 
and  vaplnal  walls ;  normal  condition,  u, 
tJrethra ;  vi,  vaj^lna  seen  in  section  as  a 
slit,  with  «  its  ritcht  lateral  sulcus;  r,  rec- 
tum ;  /,  levator  ani  muscle  (vapinal  fibres') ; 
I,  levator  ani  muscle  (rectal  fibres). 


PLASTIC   GYNALCOLOGICAL    OPERATIONS 


747 


necessary  for  the  cases  in  class  i.  and  class  ii. ;  a  full  description  of  the 
technique  to  be  adopted  in  class  ii.  will  comprehend  that  of  class  i. 

No  plastic  operation  should  be 
carried  out  without  full  antiseptic  $.  "'••..   ^^<;:ZI^IIi;:^^\       ...u 

precautions;    these  are  completely  ""yVx^    0' 

described    in   Dr.   Amand   Routh's  „. 

paper   on    "Gynaecological    Thera-    '^''' 7/^fe^  1^"^  Vw/i'W^ 

peutics,"  p.  249.  /,/ /y^^^'^"^'^     ''^^ 

^%.         K:^^ \\ ^' 

Plastic    Operation    for    Complete     ^ 

Laceration         of        the       Perineum 

(class  ii.).  —  There  is  no  procedure 

which,  besides  manual  dexterity,  Fio.  ISG.— Relations  of  levator  tinl  to  the  rectum 
vpnnirp<!     PTPnfpr    pqi-P     in     flip     nrP  ^""^    vaginal    walls;    injured    condition.      A 

leqUlies     giearer    Caie     m     Uie     pre-  deep  tear  thmusxh  the  va-inal  and  rectal  fibres 

paratory  and  after  treatment  than  producing  effacement  of  sulcus,  and  a  patu- 

1         -1  T     •  1  ,  lous  v.afjina.     u.  va,  k,  r.  as  in  Fifr.  \o6 :  n'. 

perineorrhaphy;      and     in     order    to  altered  va-inal  sulcus  •//„   torn   rectal   .ind 

describe  it  accurately,  it  is  necessary  vaginal  fibres;   ;,,,  normal  condition.     (Dia- 

,  iT-i,i  ^  •      j_    •    j_       1}  grammatic  form  below.) 

to  subdivide  the  subject  into  four 

headings  :  (a)  Preparator}'^  treatment ;  (b)  Denudation  ;  (c)  Suturing ; 
(d)  After  management.  A  fifth  procedure,  namely,  stretching  of  the 
lacerated  sphincter,  is  often  inserted  between  the  first  and  second  of 
these,  and  is  certainly  useful  in  some  cases. 

(a)  Preparatory  Treatment.  — The  operation  is  performed  under  most 
favourable  circumstances  a  week  or  ten  days  after  the  cessation  of 
menstruation,  and  shortly  after  the  patient's  return  from  country  or  sea 
air.  At  least  two  months  should  have  elapsed  since  the  labour  in  which 
the  injury  Avas  inflicted ;  the  urine  must  be  examined  to  ascertain  the 
absence  of  albumin  and  sugar.  If  the  woman  be  nursing  her  child  it  is 
better  to  wean  it.  For  seven  days  the  patient  should  be  placed  upon 
light  diet  —  fish,  eggs,  and  broth  —  and  is  better  in  bed,  though  this  is  not 
essential ;  some  observers  forbid  the  use  of  milk  as  apt  to  produce  constipa- 
tion. In  order  to  get  rid  of  all  scybala  from  the  large  intestine,  a  pill 
composed  as  follows  should  be  given  every  evening  at  bed-time  for  a 
week:  —  I^  Extr.  aloes  liq.  gr.  iss.-iiss.,  Pil.  col.  c.  cal.  gr.  ij.,  Extr. 
cascar.  sagrad.  gr.  iss.,  Extr.  belladonnae  gr.  ^  —  the  doses  being  so 
regulated  as  to  produce  two  liquid  motions  daily.  The  night  l)efore  the 
operation  a  full  dose  of  ol.  ricini  should  be  administered,  and  a  simple 
enema  an  hour  before.  For  twenty -four  hours  immediately  preceding  the 
operation  absolute  rest  in  bed  is  necessary,  and  soup  and  barley  water 
only  as  diet.  During  this  week  hot  vaginal  douches  (temp.  110°  to 
120°  F.)  of  1  in  4000  corrosive  sublimate  solution  should  be  adminis- 
tered thrice  daily  ;  these  relieve  congestion,  soften  the  tissues,  and  pre- 
vent excessive  venous  oozing  during  the  process  of  denudation.  Should 
there  be  much  leucorrhoea  the  douche  may  be  followed  by  the  introduc- 
tion of  a  glycerine  pledget,  which  protects  the  irritated  surfaces  from 
the  discharge.  Some  operators  are  accustomed,  a  few  days  previously, 
to  divide  subcutaneously  those  scars  which  appear  to  distort  the  parts, 


74S  SYSTEM   OF  GYNECOLOGY 

and  are  likely  to  interfere  with  tlie  healing  process ;  this  procednre, 
however,  is  open  to  question. 

Should  the  bowels  have  failed  to  act  just  before  the  anaesthetic  is 
given,  on  its  administration  the  rectum  should  be  swabbed  out,  and  any 
masses  removed  with  the  blunt  spoon. 

As  the  rectum  communicates  directly  with  the  site  of  the  operation, 
strict  asepsis  is  impossible ;  at  the  same  time  contamination  must  be 
prevented  as  far  as  circumstances  allow.  The  patient  should  lie  in  the 
dorsal  position,  with  her  knees  supported  and  separated  by  a  crutch ;  a 
mackintosh  sheet,  over  which  is  a  towel  soaked  in  1  in  4000  mercurial 
solution,  should  be  laid  under  the  buttocks  ;  and  a  flat  tray  half  filled  with 
1  in  20  carbolic  acid  solution,  and  containing  the  necessary  instruments 
(recently  boiled)  is  placed  within  easy  reach  of  the  operator,  Avho  should 
have  gone  through  the  usual  purifying  process  on  his  own  person. 

Through  a  Sims'  speculum  the  vaginal  mucous  membrane  and  the 
site  of  the  rupture  should  be  thoroughly  and  firmly  rubbed  over  with 
cotton  wool  wetted  with  1  in  1000  solution ;  the  labia  and  parts  about 
the  perineum  are  shaved,  and  then  purified,  first  with  soap  and  water, 
afterwards  with  the  perchloride  solution. 

The  instruments  necessary  for  the  operation  are  (1)  six  pairs  of 
Spencer  Wells'  artery  forceps;  (2)  artery  catch  forceps;  (3)  long 
dissecting  forceps,  preferably  with  hooked  ends  ;  (4)  a  pair  of  sharp 
pointed  angular  scissors;  (5)  needles  of  various  curves;  ((>)  a  needle 
liolder,  either  Spencer  Wells'  or  Hagedorn's,  according  to  the  needles 
in  use. 

Some  operators  stretch  the  sphincter,  others  comdemn  this  practice ; 
among  the  latter  is  Emmet.  The  reason  for  stretching  is  that  when  the 
torn  ends  of  the  sphincter  are  sutured,  the  irritation  from  collection  of 
flatus  and  the  bruising  of  the  parts  during  the  operation  are  productive 
of  much  reflex  muscular  contraction,  which  must  prevent  firm  union  or 
seriously  interfere  with  it.  If  stretching  be  done  before  suturing  the 
muscle  remains  paralysed  for  forty-eight  hours  at  least,  and  good  union 
takes  place ;  moreover,  after  stretching,  the  ends  of  the  contracted 
spliincter  are  more  easily  accessible.  The  manrouvre  is  carried  out  by 
grasping  the  tissues  firmly  on  one  side,  over  tlie  depressed  end  of  the 
si)hincter,  with  the  thumb  and  first  finger  of  one  hand,  and  forcibly 
stretching  the  contracted  muscle  with  the  other ;  this  action  is  repeated 
(m  the  other  side. 

(h)  Denvflation  may  be  carried  out  either  by  paring,  that  is,  removing 
a  superficial  kiyer  of  mucous  membrane  with  tlie  knife  or  scissors  in  order 
to  leave  a  bare  surface,  or  by  tlu^  metliod  termed  "flap-s]»litting."  The 
latter  process  is  now  generally  adojited,  and  must  be  cansFully  described. 

Thepatientbeinganaistlietisedand  lying  in  the  dorsal  position,  the  skin 
over  the  circular  dej)ressions  (Fig.  157,  s  a^  corresponding  to  the  severed 
sphincter  muscle  (k)  is  seized  with  the  hook  dissecting  forceps  and  slightly 
raised;  with  the  scissors  this  portion  of  skin,  say  on  the  right  side,  should 
be  excised,  a  procedure  which  bares  the  torn  end  of  the  muscle  and  opens 


PLASTIC   GYNyECOLOGICAL    OPERATIONS 


749 


Fig.  157. —  Perineorrhaphy  ;  preliminary 
incisions,  c/,  Clitoris  ;  m,  urethral 
orifice  ;  ^J)i.,  labium  minus  ;  a.v.w., 
anterior  vaginal  wall;  p.v.ic,  pos- 
terior vaginal  wall ;  k,  retracted 
sphincter.     (Diagrammatic) 


up  the  cellular  tissue.     The  same  manoeuvre  is  carried  out  on  the  opposite 

side.     The  point  of  one  blade  of  the  scissors  is  now  buried  in  the  loose 

tissue  at  this  bare  spot  on  the  right  (opera- 
tor's) side  (Fig.  157,  s),  and  carried  along  the 

edge  of  the  vaginal  opening  between  the 

superficial  and  deep  tissue,  until  a  point  is 

reached  above  the  level  of  the  apex  of  the 

triangle  formed  by  the  rent  of  the  recto- 
vaginal septum  (Fig.  157,  a) :  a  few  snips  of 

the  scissors  will  complete  the  incision ;  a 

similar  manoeuvre  is  carried  out  on  the 

other  side  (Fig.  157,  h).     Starting  again 

from  the  denuded  spot  (s),  the  point  of  the 

scissors  is  carried  along  the  edge  of  the 

recto-vaginal  septum  in  the  direction  of 

the  arrow,  separating  it  into  an  upper  and 

lower  flap.     A  similar  incision  beginning 

at  s^  meets  this  one  at  the  apex  of  the 

triangle  (c).     If  now  the  angles  at  s  and  s^ 

be  raised  by  catch  forceps,  and  the  scissors 

passed  carefully  into  the  cellular  tissue,  it  will  be  seen  how  easily  a 

flap  is  raised  from  the  recto-vaginal  septum  (Fig.  158,/),  leaving  a  raw 

bilobed  surface.  In  Fig.  158  the  flap  has 
been  raised,  and  it  will  be  found  that  .s 
and  IV,  s^  and  w^  are  corresponding  letters 
on  the  bare  surface  and  flap  respectively  : 
the  first  finger  of  an  assistant's  hand  in 
the  rectum  aids  very  much  in  bringing 
the  different  parts  under  the  action  of  the 
scissors.  This  flap  may  be  now  cut  away 
if  there  be  a  redundancy  of  tissue,  as  is 
sometimes  the  case ;  otherwise  it  is  drawn 
up  out  of  the  way  by  a  tenaculum  and 
left  to  be  dealt  with  later.  The  bleeding 
surface  should  be  lightly  swabbed  over 
with  small  pieces  of  cotton  wool  dipped 

„     ,.o     _  .       ,    ,      ,      ,   ,       in  1  in  4000  solution  and  wrung  nearly 

Fig.  1.58. — Penneorrhaphv  ;  denuaation.      -  -i 

Flap (/) raised  by  teiiacuUiu^);  k,   dry.     HsBmorrhage  soou  ceascs,  as  a  rule, 
ci,  M,  i.771.,  as  in  Fig.  157.  owing   to    the    pinching    action    of    the 

scissors ;  but  if  it  continue,  a  hot  douche  of  water  at  110°  F.  should  be 
played  over  the  wound,  and  a  sponge  wrung  out  in  water  at  the  same 
temperature  pressed  upon  it  at  intervals;  if  a  distinct  bleeding  vessel 
can  be  made  out,  it  must  be  seized  with  a  Spencer  Wells'  forceps,  which 
will  remain  attached  until  the  sutures  are  passed. 

(c)  Passage  of  the  Sutures.  —  The  most  suitable  material  is  carbolic 
silk;  but  silver  wire,  chromic  catgut,  and  silkworm  gut  are  also  exten- 
sively used  by  their  respective  advocates :  a  silk  suture  appears  to  me 


750 


SYS'J'EM  OF  GYNECOLOGY 


to  have  tlie  greatest  advantages.     Two  sizes  are  required  —  a  very  fine 

one  for  repair  of  the  torn  recto-vaginal  septum,  and  a  slightly  stouter 

material  for  the  perineum  proper. 

Closure  of  the  recto-vaginal  rent  may  be  performed  in  two  ways  :  —  by 

the  "  purse-string  "  suture,  and  by  the  interrupted  "  buried  "  suture. 

Fig.  159  illustrates  the  former  method ; 
the  point  of  a  fine  half  curved  needle,  in 
its  holder,  enters  the  cut  edge  of  the 
sphincter  at  the  point  b;  it  is  then  passed 
up  parallel  with  one  side  of  the  rent  to 
the  apex  of  the  triangle  c,  brought  down 
on  the  other  side  and  out  through  the 
other  cut  end  of  the  sphincter  a.  The  two 
ends  are  tied  tightly,  so  that  the  points  a, 

Fig.  159.  —  Purse-stnng  suture ;   suture  ■        i     ^  iji  t 

passed,    a,  b,  Denuded  ends  of  b,  and  c  are  approximated,  and  the  muscle 
sphincter;  c,  angle  of  rent.  repaired.      Failure  in  operations  on  the 

perineum  is  chiefly  due  to  faults  in  passing  the  sutures ;  hence  it  is  of  the 

utmost  importance  that  the  severed  ends  of  the  sphincter  should  be 

carefully  brought  together.   The  lat- 
ter procedure  is  more  satisfactory, 

and  consists  in  passing  a  series  of 

sutures  an  eighth  of  an  inch  apart  as 

shown  in  the  diagram  (Fig.  160).    A 

needle  threaded  with  very  fine  silk  is 

passed  through  one  edge  (operator's 

left)  of  the  rent  from  below ;  it  is 

then  carried  over  the  laceration,  and 

through  the  edge  on  the  opposite 

side,  from  above  downwards,  so  that 

when  tied  the  knot  will  lie  in  the 

rectum  itself.    Five  of  these  sutures 

are  generally  necessary,  each  being  tied  before  the  next  is  passed ;  the 

lowest  is  of  the  greatest  importance,  as  by  it  the  bulk  of  the  sphincter  is 


Fig.  160. — Perineorrhaphy;  repair  of  the  recto- 
vaginal septum.  Sutures  2  and  5  are  passed  to 
show  direction  taken  by  the  needle  ;  the  sites 
of  ingress  and  egress  of  the  others  are  indi- 
cated by  dots  with  a  corresponding  figure. 


Fio.  ICl.  —  I.  Section  of  torn  sphitjctiT  («),  with  sutiirfi  i/j  o  [iroperly  pas.scd.     2.   Iiiii)roperly  passed. 

repaired  (Fig.  160,  5j ;  if  tlie  little  finger  l)o  passed  into  the  newly  made 
anus  as  the  patient  recovers  consciousness,  it  will  be  grasped  tightly. 


PLASTIC    GYNECOLOGICAL    OPERATIONS  751 

It  is  now  seen  that  a  somewhat  renif orm  raw  surface  is  left,  as  in  an 
incomplete  rupture  of  the  perineum  already  described,  the  repaired  recto- 
vaginal septum  forming  a  central  vertical  line  in  its  lower  part  (Fig.  162j : 
repair  of  this  injury  is  extremely  simple.  The  needle  selected  should  be 
longer  and  stouter  and  the  suture  thicker  than  for  the  preceding  step  of 
the  operation.  The  point  of  the  needle  is  entered  on  the  skin  surface 
close  to  the  raw  edge,  and  pushed  across  the  recto-vaginal  septum  be- 
neath the  denuded  surface,  emerging  on  the  skin  on  the  opposite  side. 
Three  other  sutures  are  passed  in  the  same  way  (i.  11.  iii.  iv.). 

Nothing  further  should  be  done  ty 

until  bleeding  ceases;   the  Spencer  ''~~Y^^^---~^^^^>^^^^'^^^^----^^ 

Wells'  forceps  can  now  be  taken  off,  /                                      \ 

and  if  the  surface  remain  fairly  dry    -— 'r \"     -^^ 

an  antiseptic  douche  may  be  played  I                                           / 

over  the  wound,  and  the  sutures  tied  \^ ''}}       " -/.^ 

or   the   wires   twisted.     Any   blood  \.       .;;;| ^      / 

flowing  after  the  co-adaptation  of  the  ^X^ — ^ *^^t 

flaps  or  clots  may  break  down  into  pus     ^^^    ^g^.  -Perineorrhaphy  ;   recto.va„^Dal  sep- 
and   prevent  union.      As  the    sutures  tum  repaired,  the  four  superficial  or  peri- 

are  being  secured  the  legs  must  be  "'^''^  ^"^"^^^  p''^^"'*'  ^"'  °***  ""'^• 
brought  together  and  tied  at  the  knees.  The  sutures  should  not  be 
tied  too  tightly;  practice  only  can  enable  the  operator  to  gauge  the 
proper  amount  of  tension.  Some  local  swelling  always  follows  the 
operation.  If  at  any  part  of  the  wound  the  edges  are  not  quite  in 
apposition,  it  is  well  to  insert  one  or  more  superficial  catgut  stitches. 
The  wound  is  now  dusted  over  with  iodoform  powder;  the  urethral 
orifice  is  shown  to  the  nurse  in  attendance  to  enable  her  to  pass  the 
catheter,  and  a  wood-wool  diaper  is  applied  by  means  of  a  T  bandage. 
The  patient  is  then  put  to  bed  on  her  back,  or  side,  with  her  knees 
tied  together  and  supported  over  a  bolster.  No  morphia  suppository  is 
necessary,  as  the  patient  rarely  suffers  pain,  and  no  agent  likely  to  pro- 
duce constipation  should  be  administered. 

In  those  cases  in  which  it  is  not  thought  desirable  to  cut  away  the 
dissected-up  flap,  three  or  more  sutures  are  passed  through  its  sub- 
stances transversely,  and  it  is,  so  to  speak,  longitudinally  folded  upon 
itself  when  these  are  tied. 

(d)  The  After  Management.  —  Xo  opium  or  alcohol  should  be  given. 
If  vomiting  come  on  after  the  anaesthetic,  the  nurse  should  support  the 
perineum  with  the  palm  of  her  hand  flat  upon  the  diaper.  The  catheter 
is  necessary  every  six  hours,  great  care  being  taken  to  avoid  dribbling  of 
urine  over  the  wound ;  the  instrument  when  not  in  use  should  lie  in  1 
in  4000  solution.  Some  operators  insist  that  tlie  urine  should  be  passed 
naturally  from  the  beginning,  lest  the  bladder  be  infected  from  the  use 
of  the  catheter.  No  food  is  necessary  for  at  least  twelve  hours ;  tlien 
only  barley-water  and  milk,  a  teasjwonful  at  a  time.  Fluid  diet  only 
should  be  administered  for  twenty-four  hours  after  the  operation  ;  gruel 
and  bread  and  milk  may  be  given  on  the  second  and  third  days.     A 


752 


SYSTEM   OF  GYNAECOLOGY 


purgative  of  the  same  composition  as  that  given  before  the  operation 
must  be  administered  on  the  evening  of  the  tliird  day,  or  even  earlier; 
some  operators  give  an  aperient  within  twenty-four  hours.  Castor  oil  is 
of  great  value,  but  is  often  objected  to  by  the  patient;  the  compound 
liquorice  powder  in  3j.  doses  is  useful.  A  very  efficacious  plan  is  to 
give  a  teaspoonful  of  saturated  solution  of  Epsom  salts  every  half  hour 
until  the  required  result  is  attained.  Platiis  may  be  relieved  by  pass- 
ing a  catheter  into  the  rectum,  keeping  it  carefully  pressed  along  the 
posterior  rectal  wall  during  introduction.  If,  before  the  action  of  the 
bowels  takes  place,  the  patient  be  aware  of  a  scybalon  in  the  rectum,  a 
small  amount  of  olive  oil  may  Avith  great  advantage  be  injected  into 
the  bowel  through  a  No.  8  male  catheter. 

After  an  action  of  the  bowels  the  rectum  should  be  washed  out  with 
a  solution  of  boracic  acid,  to  prevent  contamination  of  the  rectal  sutures. 
It  was  formerly  customary  to  keep  the  bowels  quiet  until  the  sixth 
or  seventh  day  ;  but  it  was  found  by  experience  that  the  scybala  tore 
open  the  recently  healed  tissues.  The  object  of  the  more  modern  treat- 
ment is  to  get  early  but  liquid  motions.  No  antiseptic  vaginal  douches 
are  necessary ;  but  twice  daily  the  external  genitals  may  be  washed 
with  a  1  in  4000  mercurial  solution,  and  the  gauze  pad  frequently 
changed  to  keep  the  wound  dry.  The  sutures  should  be  removed  on 
the  tenth  day  or  before  if  they  produce  any  irritation ;  a  distinct  rise 
in  temperature,  with  a  sensation  of  throbbing  about  the  parts,  followed 
by  a  purulent  discharge,  indicates  that  suppuration  has  taken  place  in 
some  part  of  the  wound. 

Various  modifications  of  the  above  method  are  in  use,  but  of  these 

two  only  need  be  described  here ;  namely,  that  of  Hegar,  who  modified 

Simon's  operation  (the  "  Simon-Hegar  "),  and  that  of  A.  Martin  of  Berlin. 

ly  j^  Afterwards  I  shall  describe 

Alexander  Duke's  mode  of 
repair,  which  is  on  an  en- 
tirely different  plan. 

The  ^^Simon-Hegar"  Op- 
eration for  complete  Perineal 
Rapture.  —  The  principle 
iipon  which  this  method  is 
founded  assumes  that  the 
perineal  body  is  torn  on  three 
surfaces,  and  that,  to  be  suc- 
y  \j  cessful  in  repairing  the  rent, 

Fkj.  lG3.-Perinc-orrhai.tiyrSirrioii-II(;f,'ar method  of  Butnre).  SUturCS  must  be  inserted  OU 
a,  Antfleof  reoto-vittrinal  rent;  rf(^„  sitosoftorri  ends  the  Vaginal,  rectal,  and  BX- 
i)f  lacerated  sphincteririuficlo;  c,  central  tonpuodenuded     ,  i  •  i  p 

and  two  ButureH,  1  1„  2  2,,  passed  ;  h  h„  extreiuitios     temai   perineal   SUrtaCCS. 
of  denuded  surfaces  on  labia  niajora.  The    shapC    of    the    fresh- 

ened surface  maybe  compared  in  shape  to  a  butterfly,  the  recto-vaginal 
septum  being  the  body,  and  a  tongue-shaped  projection  (Fig.  103,  c) 
the  head. 


PLASTIC   GYNAECOLOGICAL    OPERATIONS 


753 


To  mark  out  the  area  to  be  denuded  a  Sims'  speculum  is  inserted 
to  retract  the  anterior  vaginal  wall ;  and  plugs  of  iodoform  gauze  are 
pushed  into  the  rectum  to  prevent  passage  of  faeces  over  the  wound 
about  to  be  made. 

The  hooked  forceps  should  seize  the  mucous  membrane  at  the  point 
c,  which  point  should  be  in  the  median  line  of  the  recto-vaginal  septum, 
and  two  cm.  above  the  apex  (a)  of  the  tear  through  the  sphincter.  Two 
other  points  to  be  marked  out  are  the  extremities  to  which  denudation 
is  to  take  place  on  the  inner  surfaces  of  the  labia  majora  (b  b,).  This 
butterfly-shaped  area  must  now  be  bared  of  its  mucous  membrane  by 
means  of  a  knife  or  scissors ;  there  is  no  flap-splitting. 


Fio.  164. 

A.  Simon-Hegar  method  of  suture,  2nd  stage.     The  sutures  1  1,,  2  2,,  in  the  tongue  c,  have  been  tied 

1  1,,  5  5,,  Vaginal  sutures  passed  ;  p^  p,,  /),,  />,,.  perineal  sutures  passed. 

B.  Simon-Hegar  method  completed  (side  view),     a,  Vaginal  sutures  tied  ;  h,  perineal ;  c,  rectal. 

Lateral  venous  sinuses  may  give  rise  to  troublesome  bleeding,  but 
otherwise  the  haemorrhage  requires  no  treatment.  Hegar  warns  opera- 
tors against  baring  too  extensive  a  surface,  for  when  so  much  tissue  is 
included  between  the  stitches,  suturing  is  rendered  much  more  difiieult 
and  union  less  likely  to  take  place. 

The  small  central  tongue  should  first  be  sutured  and  the  stitches 
tied ;  two  or  three  are  sufficient  (Fig.  164,  A,  c).  This  is  supposed  to 
give  additional  solidity  to  the  recto-vaginal  septum.  Next  the  sphincter 
should  be  repaired,  the  needle  being  passed  as  is  indicated  in  Fig.  1G4,  A, 
Pi  Pij.  The  knots  of  these  sutures  will  lie  in  the  anterior  rectal  wall. 
The  vaginal  and  perineal  stitches  are  next  inserted  in  the  usual  way. 

The  after  treatment  is  as  in  the  preceding  operation,  Avith  the  excep- 
tion that  Hegar  recommends  a  purgative  to  be  given  on  the  fifth  day, 
and  that  as  soon  as  two  free  actions  have  taken  place  no  more  aperients 
be  administered. 

A.  3rartin^s  Method.  —  The  denuded  surface  is  the  same  as  is  recom- 
mended by  Hegar  and  Simon,  but  the  mode  of  suture  is  quite  different. 
The  flaps  are  brought  together  by  the  use  of  the  continuous  suture  in 
superimposed  layers  (vide  Figs.  169-171).    The  needle  is  entered  at  the 

3c 


754 


SYSTEM  OF  GYNAECOLOGY 


apex  of  the  central  triangle  (Fig.  163,  c)  and  continued  downwards,  so 
as  to  unite  the  edges  of  the  recto-vaginal  septum  and  thus  repair  the 
sphincter ;  an  upward  direction  is  now  taken  with  the  next  superimposed 
layer,  and  finally  the  direction  of  the  needle  is  again  changed,  and  makes 
a  series  of  superficial  stitches  from  above  downwards.  Greater  rapidity 
in  the  performance  of  the  operation,  and  a  closer  adaptation  of  the  raw 
surfaces,  are  the  chief  objects  attained  in  this  method. 

Alexander  Duke^s  Method.  —  This  author  published  his  mode  of  pro- 
cedure in  the  Dublin  Medical  Press  (9th  May  1888) ;  he  considers  it  to 
be  easy  of  performance  and  to  make  a  good  j)erineal  floor. 

The  patient  being  prepared  in  the  usual  way,  anaesthetised,  and 
placed  in  the  dorsal  decubitus,  the  left  index  finger  is  introduced  for 
almost  its  entire  length  into  the  rectum.  "A  long,  straight,  double- 
edged  bistoury  is  now  made  to  pierce  the  tissues  in  front  of  the  anus  at 
right  angles  to  the  vtdva,  and,  guided  by  the  finger  in  the  rectum,  is  made 
to  penetrate  the  septum  for  two  and  a  half  inches  "  in  an  upward  direc- 
tion. The  incision  may  then  be  bilaterally  widened 
to  two  inches  as  the  knife  is  withdrawn  (Fig.  165, 7c  k^). 
The  patient  being  placed  in  the  left  lateral  posi- 
tion, and  the  points  k  k^  of  the  incision  being  pressed 
together,  a  lozenge-shaped  opening  will  be  made; 
sutures  are  passed  in  order  to  bring  these  raw  sur- 
faces together. 

The  sutures  are  introduced  by  means  of  a  "  strong 
sickle-shaped  needle  "  (with  the  eye  near  the  point) 
mounted  on  a  handle.  For  suture  the  author  prefers 
silver  wire  to  any  other  material. 

The  needle  is  entered  unthreaded  at  the  edge  of 
the  incision  on  one  side  and,  guided  by  a  finger  in 
the  rectum,  is  made  to  travel  under  the  raw  surface 
to  its  full  depth  above,  thus  describing  the  arc  of  a 
circle;  as  the  point  of  the  needle  appears  directly 
opposite  the  wire  is  drawn  through  the  eye :  other 
sutures  are  passed  in  a  similar  manner. 

If,  after  tying  the  stitches,  a  finger  of  each  hand 
be  passed  into  the  rectum  and  vagina  respectively, 
the  septum  will  be  found  much  thicker,  and  the 
external  tissue  pushed  fully  an  inch  forward  from 
the  anus. 

])r.  Duke  claims  throe  great  advantages  for  this 
method :   (1)  simplicity  of  performance  and  no  fear 


(3) 


tt a 

Fifi.  10.0.  —  Alexandor 
Ouke's  method.  (1) 
TranKvorse  inoiHioii 
(fc  k,)  made;   (2)  con- 


vfiridon  of  Incision  in-  .  ..... 

to  a  lozenge  -  shaped  of  liaimorrliagc ;  (2)  uo  risk  of  sepsis,  as  tho  lucision 
ITitures  ^'^rl'anuT'cf  ^^  "^^  oi^eii  for  the  admission  of  any  discharge  from 
clitoris;  il,  uietiuai  either  vagina  or  rectum  during  healing;  (3)  no  loss 
"■■'"'=''•  of  tissue. 

Plastic  Operations  for  Lacerations  of  the  Pelvic  floor  Proper  (class  iii.). 
—  The  trcatiiKMit  to  be  adopted  in  these  cases  differs  very  materially 


PLASTIC   GYNECOLOGICAL    OPERATIONS 


755 


from  the  preceding:  the  objects  to  be  attained  are,  first,  to  suture  the 
torn  ends  of  the  levator  to  the  lateral  vaginal  sulcus  and  perineum, 
and,  secondly,  to  draw  up  or  "lift"  the  pelvic  floor. 

The  patient,  both  as  regards  diet  and  antiseptic  precautions,  is  pre- 
pared as  in  the  former  case  ;  and  is  placed  in  the  dorsal  decubitus.  A 
Sims'  speculum  is  inserted,  and  so  placed  as  to  elevate  the  anterior 
vaginal  wall ;  the  lateral  sulci  and  the  posterior  wall  are  thus  exposed. 


=^2" 


ma 

.  Ififi.  —  Surface  view  of  posterior  ynfjinal  wall 
with  right  and  left  lateral  sulci ;  the  anterior 
wall  sui)posed  to  be  removed  :  on  left  side 
(patient's)  sutures  inserted,  right  side  as  the 
.sulcus  appears  untouched.  1  to  5  sutures  ; 
their  mode  of  passage  being  indicated  by 
arrows  ;  h,  hymeneal  edge  \tt  ,  sites  of  attach- 
ment of  tenacula  ;  r,  crest  of  rectocele. 


Fig.  167.  —  Same  view  as  Fig.  16C. 
^vith  both  lateral  vaginal  sulci 
sutured,  1,  "2,  .S,  4,  5.  Quadri- 
lateral raw  surface  with  sutures 
passed  p-^,  p„,  ;<,,.  p^.  p^,  but  not 
tied ;  i\  crest  of  rectocele ;  (t. 
anus  ;  h,  t  ?,,  as  before. 

With  the  left  forefinger  in  the  rectum  the  space  to  be  denuded  is 
mapped  out  by  means  of  the  sharp-pointed  scissors,  as  shown  in  Fig.  166, 
the  base  line  of  the  double  triangle  being  formed  by  the  site  of  the 
hymen  {\i) :  it  is  best  marked  out  by  inserting  a  tenaculum  about  three- 
quarters  of  an  inch  from  the  urethra  on  each  side  {t  t),  and  using  slight 
tension.  The  tip  of  the  tongue  between  the  two  triangles  should  bo 
situated  on  the  most  prominent  point  or  crest  of  the  rectocele  (Figs. 
KU)  and  167  r).  The  Avhole  of  the  incisions  must  be  contained  in  the 
vagina,  and  not  extend  to  the  vulva.  The  mucous  monibraue  is  now 
removed  from  this  M-shaped  space,  particular  care  being  taken  to  go 
deep  enough  into  the  sulci ;  bleeding  is  rarely  severe  enough  to  require 
the  application  of  ligatures. 

The  insertion  of  the  sutures  is  begun  at  the  upper  angle,  usually  on  the 
left  side  (patient's)  and  after  the  manner  shown  in  Fig.  166.  The  suture 
(1)  is  passed  from  the  outside  towards  the  median  lino ;  not  straight  across. 


756  SYSTEM  OF  GYNAECOLOGY 

but  first  downAvards  and  inwards  to  the  centre  of  the  denuded  surface,  and 
then  upwards  and  outwards  towards  the  mucous  membrane  through  the 
tongue  of  the  flap,  as  shown  by  the  arrows  in  the  figure :  a  series  of  four 
or  five  of  these  sutures  are  passed  in  a  similar  manner.  On  inspection  of 
Fig.  156,  which  is  an  imaginary  transverse  section  parallel  to  one  of  these 
sutures,  it  will  be  seen  that  the  torn  ends  of  the  levator  are  sutured  to  the 
relaxed  sulcus,  and  on  tying  the  knot  complete  restoration  of  the  parts  to 
their  original  integrity  results.  Having  completed  the  left  triangle  the 
right  is  treated  in  the  same  Avay,  and  we  find  that  a  roughly  quadrilat- 
eral raw  surface  is  still  left  below  (Fig.  167)  ;  this  is  united  by  passing 
and  tying  four  or  more  transverse  buried  sutures  as  in  the  operation  for 
incomplete  perineal  rupture :  a  Y-shaped  cicatrix  should  be  the  result. 

The  after  treatment  is  exactly  as  detailed  in  class  ii. ;  the  sutures 
usually  remain  buried,  cause  no  irritation,  and  do  not  require  removal. 

This  is  practically  the  operation  devised  by  Emmet,  and  the  steps  of 
it  are  with  very  few  exceptions  the  same  as  those  laid  down  by  him 
twenty-five  years  ago.     .' 


B.    OPERATIONS    FOR    DISPLACEMENTS    OF    THE    PELVIC    FLOOR 

Prolapsus  uteri  may  be  looked  upon  "as  a  downward  and  outward 
displacement  of  the  entire  displaceable  portion  of  the  pelvic  floor,  past 
the  entire  fixed  portion,"  with  eversion  of  the  walls  of  the  vagina  (Berry 
Hart).  Simple  prolapsus  may  be  complicated  by  more  or  less  procidentia 
of  the  anterior  and  posterior  vaginal  walls,  and  by  a  varying  amount  of 
hypertrophy  of  the  cervix.  Prolapse  of  the  anterior  vaginal  wall  may 
occur  alone  or  carry  the  posterior  bladder  wall  down  with  it  (cystocele). 
Both  conditions  are  frequently  cured  by  the  same  operation  (anterior 
colporrhaphy),  although  for  the  latter  a  special  one  has  been  devised 
(Stoltz).  In  a  similar  manner  prolapse  of  the  posterior  wall  may  be 
simple;  or  there  may  be  in  addition  a  displacement  downwards  of  the 
anterior  rectal  wall  (rectocele) :  both  of  these  are  treated  by  elytro-  or 
colpoperineorrhaphy.  The  operative  treatment  of  cystocele,  enterocele, 
urethrocele,  and  prolapse  of  the  urethral  mucous  membrane  will  be  con- 
sidered seriatim. 

Hypertrophy  usually  affects  the  body  of  the  uterus  (metritis)  ;  ap- 
parent cervical  hypertrophy  is  the  result  of  the  prolapsus  :  a  differential 
diagnosis  must  therefore  be  made  from  congenital  hypertrophy  of  the 
vaginal  and  the  supravaginal  cervix.  As  prolapsus  uteri  is  usually 
attended  by  retroversion  of  the  fundus  this  latter  condition  may  require 
treatment. 

For  the  purpose  of  selecting  a  suitable  operation  in  each  case  it  is 
better  to  divide  these  lesions  into  four  divisions:  — 

(<i)  Prolapsus  uteri  and  procidentia  vaginai  (cystocele  and  rectocele, 
etc.),  associated  with  cervical  hypertrophy.  (6)  Prolapsus  uteri  and  pro- 
cidentia vaginae,  without  cervical  hypertrophy,    (c)  Prolapsus  uteri,  with 


PLASTIC   GYNECOLOGICAL    OPERATIONS 


111 


retroversion  and  procidentia  vaginae.     (^  Simple  procidentia  vaginae 
without  uterine  prolapse. 

The  various  plastic  operations  to  which  resort  can  be  had  for  the 
relief  of  the  above  conditions  are  :  — 

(i.)  Those  performed  chiefly  with  the  object  of  giving  support  to  the 
prolapsed  parts  by  repairing  the  perineum  (perineorrhaphy) ;  or,  in  addi- 
tion to  this,  suturing  together  the  inner  edges  of  the  pared  labia  ma- 
jora  (episio-perineorrhaphy).  (ii.)  Those  performed  with  chief  object 
of  narrowing  the  vaginal  walls  (elytro-  or  colporrhaphy),  or  making  a 
vaginal  partition  (Lefort's  operation),  (iii.)  Combinations  of  i.  and  ii. 
(elytro-  or  colpoperineorrhaphy).  (iv.)  Those  for  prolapse  of  the  pos- 
terior bladder  wall  with  anterior  vaginal  wall  (cystocele)  of  the  urethra 
(urethrocele),  of  the  urethral  mucous  membrane,  and  of  the  intestines 
(vaginal  enterocele).  (v.)  Those  tending  to  cure  the  metritis  and  cer- 
vical hypertrophy  (curettage,  cervical  amputation),  (vi.)  Those  for  the 
relief  of  the  retroversion  (vaginal  fixation  or  hysteropexy). 

(i.)  Operations  performed  with  the  chief  object  of  giving  support  to 
the  prolapsed  parts  by  perineorrhaphy  or  episio-perineorrhaphy. 

(a)  Peritieorrhaphy  or  suture  of  the  perineum  has  already  been  de- 
scribed (p.  747).  Since  the  site  of  the  operation  scarcely  includes  the 
vaginal  walls,  it  does  not  prevent  their  eversion  ;  although  it  may  con- 
tract the  vulvar  outlet.  It  is  a  useless  and  inadequate  procedure  in  any 
but  the  mildest  cases,  and  simply  enables  a  pessary  to  be  retained. 

{fi)  Ephio-perineorrhapliy.  This  operation  consists  in  paring  the  inner 
and  lower  borders  of  the  external  labia 
in  addition  to  the  perineal  surfaces,  and 
suturing  the  opposing  denuded  areas  to- 
gether. The  same  objection  obtains  here 
as  in  perineorrhaphy  and,  except  for  the 
purpose  of  supporting  a  pessary,  it  is 
found  to  be  equally  useless. 

(ii.)  Operations  performed  with  the 
object  of  narrowing  the  vaginal  walls. 

(a)  Eh/trorrhaphy  or  Colporrhaphy.  — 
Sims'  method.  This  is  only  performed  on 
the  anterior  vaginal  Avail  (anterior  colpor- 
rhaphy) ;  as  originally  devised  a  V-shaped 
surface  was  denuded,  with  the  apex  point- 
ing downwards  and  commencing  just  above 
the  \;rethra.  On  suturing  these  surfaces 
together  a  pocket  was  found  to  exist  near 
the  cervix  into  which  the  latter  was  liable 
to  become  incarcerated.  Sims  therefore 
added  two  short  transverse  denudations 
at  the  ends  of  this  V  (Fig.  168,  a  a,)  ;  on 
passing  the  sutures  and  tying  them,  a 
complete  vertical  fold  of  the  anterior  vaginal  wall  is  produced,  which  in 


&■ 


-u 


Fio.  16S.  —  Elytrorrhaphy  (Sims').  The 
denudation  is  complete,  a  o,.  Trans- 
verse bared  surfaces;  1,  2,3,4,5, 
sutures  passed  ;  c,  cervix  ;  h,  ure- 
thral orifice. 


758 


SYSTEM  OF  GYNECOLOGY 


suitable  cases  will  be  found  to  act  as  an  adequate  uterine  support.  Hegar 
makes  his  denuded  surface  in  the  form  of  a  lozenge  or  rough  ellipse, 
with  the  longer  diameter  in  the  axis  of  the  vagina :  he  considers  it  use- 
less to  endeavour  to  make  the  flap  of  any  particular  shape,  and  advises 
the  excision  of  all  the  redundant  anterior  vaginal  wall.  For  practical 
purposes  the  denuded  surface  may  be  considered  as  of  a  more  or  less 
oval  shape  (Fig.  169) ;  its  upper  border  reaches  as  near  the  cervix  as 

possible  according  to  the  amount  of  mucous 
membrane  which  can  be  drawn  do^^^l  to  the 
vulva,  while  its  lower  edge  is  four-fifths  of 
an  inch  behind  the  urethral  orifice.  The 
cervix  is  drawn  down  and  steadied  with  a 
silver  wire  passed  through  its  anterior  lip. 
A  Sims'  speculum,  lateral  retractors,  or  the 
fingers  of  the  assistant,  may  be  used  to  ex- 
pose the  site  of  operation.  Having  marked 
out  the  area  to  be  denuded  with  a  scalpel, 
the  upper  edge  of  the  flap  should  be  seized 
with  hooked  forceps,  and  the  sides  steadied 
by  tenacula;  the  mucous  membrane  can  now 
be  separated  from  the  underlying  tissues 
by  means  of  a  knife  or  scissors  and  gentle 
traction :  the  edge  of  the  knife  should  always 
be  turned  towards  the  flap,  to  avoid  cutting 
too  deeply.  Bleeding  is  as  a  rule  very 
slight ;  if  it  persist,  Spencer  Wells'  forceps 
should  be  applied  and  allowed  to  remain 
attached  until  the  passage  of  the  sutures. 

Closure  of  the  wound  may  be  carried 
out  by  means  of  a  deep  and  superficial  layer 
of  interrupted  sutures ;  or  by  two  or  more 
layers  of  superimposed  continuous  sutures. 
The  latter  method  is  much  the  more  expeditious,  and  will  therefore  be 
described. 

A  small  half  or  fully  curved  needle  threaded  with  a  long  piece  of 
fine  carbolic  silk,  a  needle  holder,  and  a  pair  of  hooked  forceps  will  be 
required. 

The  first  suture  is  passed  and  tied  (but  not  cut)  near  the  urethral  end 
of  the  incision  (Fig.  109,  a) ;  the  point  of  the  needle  is  then  entered  at  b, 
is  passed  boineath  the  denuded  surface  obliquely  across  to  c,  and  then 
brought  out,  remaining  exposed  from  c  to  d ;  it  is  then  again  passed 
oblifiuely  beneath  the  surface,  in  the  direction  of  the  arrows :  as  each  loop 
is  passed  it  is  tightened,  and  the  silk  kept  taut  by  an  assistant,  while 
another  loop  is  being  passed.  In  the  figures  these  loops  are  shown  as 
still  remaining  loose  in  order  better  to  demonstrate  tlieir  mode  of  inser- 
tion. On  drawing  the  suture  tight  a  longitudinal  line  is  produced  between 
the  two  opposed  folds  (Fig.  170,  kk),  and  the  denuded  area  will  be  diminished 


,  169. — Anterior  colporrhaphy  ;  de- 
nudation and  first  layer  of  con- 
tinuous suture  completed,  a  to  s, 
course  of  suture,  tlie  dotted  por- 
tions being  buried  ;  /,  denuded 
surface  ;  x,  cervi.x  ;  t,  tenaculum  ; 
n,  needle ;  r,  vulval  outlet ;  cl, 
clitoris;  m,  urethral  orifice. 


PLASTIC   GYNECOLOGICAL    OPERATIOXS 


759 


in  size  from  side  to  side.     The  needle  being  brought  out  at  s  (Tig.  ]  69),  the 

silk  is  kept  tense,  ready  for  the  suturing  of  the  next  layer.     The  point  of 

the  needle  is  passed  superficially  from  a  to  6 

(Fig.  170)  over  the  longitudinal  line  (A;),  that 

is,  from  the  operator's  left  to  his  right.    It  is 

then  passed  back  again  in  an  opposite  and 

upward  direction  beneath  the  raw  surface, 

and  emerges  at  c;  it  is  superficial  again  from 

c  to  d,  and  buried  again  from  d  to  e ;  the  route 

taken  by  the  needle  being  in  the  direction  in- 
dicated by  the  arrows.   The  end  of  the  suture 

is  now  brought  out  at  s,  and,  if  the  denuded 

area  be  small,  it  may  be  tied  and  cut  short. 

If,  however,  a  third  layer  be  necessary,  the 

same  procedure  must  be  gone  through,  but 

from  the  urethral  end  downwards,  the  needle 

passing   through  points  of  junction  of  the 

denuded   and   mucous   surfaces   (Fig.  171). 

The  needle  has  therefore  during  the  opera- 
tion  passed  from   urethra   to   cervix,  from 

cervix  to  urethra,  and  back  again  to  cervix. 

It  is  important  to  remember  that  the  deeper 

layer  must  be  transfixed  by  the  loops  of  the 

more  superficial  layer  during  the  course  of 

the  suture  from  side  to  side. 

The  final  cicatrix  is  obviously  a  straight  line,  running  from  the  cervix 

to  just  above  the  urethra  in  the  mid- 
dle of  the  anterior  vaginal  wall. 

The  sutures  do  not  require  removal 
unless  suppuration  occurs  along  their 
track. 

(/?)  Leforfs  Operation. — This  con- 
sists in  the  formation  of  an  antero-pos- 
terior  and  longitudinal  partition  in  the 
vagina.  The  originator  of  this  opera- 
tion bases  his  practice  on  the  fact  that 
prolapse  of  the  vaginal  walls  almost 
always  precedes  that  of  the  uterus ; 
hence  if  the  anterior  and  posterior  vag- 
inal Avails  can  be  kept  in  apposition  the 
uterus  must  necessarily  remain  in  its 
normal  situation.  The  patient  is  an- 
aesthetised and  placed  in  the  dorsal 
,.    decubitus      The  uterus  is  drawn  out 

Fig.  171.  — Anterior  colporrhnphv;  passasre  of  ueLUUiuub.       xuci.nr.    o  ,       ,    , 

third  and    final    layer    of   superimposed  of    the  Vulva   tO    itS    lUllest    CXtCllt    0} 

suture.   /!-,^-„.  Site  of  seeond  layer  ;«;<„  ^^eaUS  of  a  volsclla.    Four  iucisioUS  are 

arrangement  of  silk  preparatory  to  tying  mt-aiia  uj.  a.     >jio«.iiii 

knot  to  complete  operation.  made  On  the  anterior  vaginal  surface, 


Fig.  170.  —  Anterior  colporrhaphy  ; 
passaire  of  second  continuous, 
superimposed  suture,  k  /-,,  The 
longitudinal  puckerini?  produced 
by  the  first  layer  of  suture.  The 
other  letters  as  in  Fiff.  1G9. 


760 


SVSTEJ/   OF  GYN.FCOLOGY 


enclosing  a  longitudinal  space  (Tig.  172,  /)  6  centimetres  long  by  2  wide ; 

the  upper  transverse  line  should  be  as  near  the  vulva  as  possible.     This 

area  is  denuded  in  the  usual  manner. 
The  cervix  is  now  drawn  upwards  and 
forwards,  and  a  similar  area  marked 
out  and  denuded  on  its  posterior  sur- 
face (Fig.  172,  f^.  Replacing  the 
uterus  sufficiently  to  bring  the  op- 
posed surfaces  into  contact,  as  in  Fig. 
172,  they  are  sutured  together  by  a 
series  of  right  and  left  lateral  stitches 
(1  1,,  2  2J ;  the  first  thread  (1  1 J  on 
the  patient's  left  side  being  passed 
through  the  middle  of  the  edge  of  the 
raw  area  nearest  the  cervix.  The 
uterus  is  thus  supported  by  a  firm 


Rt. 


# a 

Fig.  172.-Leforfs  oi.eiation  ;  the  anterior  nnrt     SCptum  produCCd  by  the  adhcSlOU  of 

posterior  lon-itudinai  areas  //■,  denuded,   portions  of  the  anterior  and  posterior 

Two  sutures,  1  1  ,  2  2  ,  passed  on  left  side,     '-        .       ^  ,,  ,  , 

one  on  right;  c/,  clitoris;   u,  urethral  ori-    vagiual  Walls.       The  SUturCS  are  kept 

fiee;  cy,  cjstocele ;  r,  rectocele ;  «,  anus.        -^^  f^^.  fourteen  dayS  Or    CVCU    longer. 

The  operation  is  said  by  Lefort  to  allow  of  coitus,  but  it  is  obviously  one 
which  would  be  selected  for  patients  of  more  advanced  age,  and  who 
have  ceased  to  menstruate.     Its  performance  has  been  attended  by  much 
success  in  France,  but  hitherto  it  has  not  gained  favour  elsewhere, 
(iii.)  Combination  of  i.  and  ii.  (Elytro-  or  Colpoperineorrhaphy). 


Fu; 


IT:'..  --C'olpo[i('rin(orrhaphy  (A.  Martin).     Ist  stage.     Surface  denuded,  sutures 
passed  (n ,)  and  tied  («). 


This  operation  consists  in  the  performance  of  a  posterior  colporrhaphy 
concluded  l)y  an  additional  perineorrhaphy.  The  methods  advocated 
by  A.  Martin  and  llcgar  are  those  most  in  vogue;  the  former  has  been 
selected  from  among  a  large  number  for  description.  The  advantage 
obtained  by  it  is  the  preservation  of  the  posterior  column  of  the  vagina, 


PLASTIC    GYNy^COLOGICAL    OPERATIONS 


761 


Fifl.  174. — 2nd  sta^e. 
First  layer  of  superim- 
posed suture  passed. 


which  is  very  resistant  and,  according  to  Freiind,  should  always  be 
maintained  intact. 

A.  MartirCs  Operation.  —  The  usual  antiseptic  precautions  must  be 
taken  in  this  as  in  all  plastic  operations  ;  the  patient  being  ansesthetised 
and  in  the  dorsal  position,  the  posterior  wall  of  the  vaginal  cul-de-sac  is 
seized  by  two  pairs  of  hooked  forceps,  one  on  each  side 
of  the  median  line.  Some  traction  is  put  upon  them, 
with  the  result  that  the  vaginal  column  appears 
strongly  marked.  On  each  side  of  this  are  made  two 
longitudinal  incisions ;  two  corresponding  flaps  are 
removed,  the  amount  varying  according  to  the  redun- 
dancy of  the  vaginal  walls  (Fig.  173,  a  a).  The  con- 
tinuous buried  suture  is  applied  to  each  and  two  linear 
cicatrices  result  (Fig.  174).  This  concludes  the  first 
part  of  the  operation  or  the  posterior  colporrhaphy ; 
the  perineorrhaphy  or  perineauxesis  has  now  to  be 
performed.  The  boundary  lines  are  almost  the  same 
as  in  the  operation  for  incomplete  perineal  rupture, 
the  contained  space  presenting  a  semilunar  appear- 
ance while  the  parts  are  at  rest ;  but  when  traction  is 
made  upon  its  lower  or  anal  extremity  it  assumes  a 
lozenge  shape  (Fig.  174).  The  deep  and  superficial 
superimposed  buried  suture  is  now  passed  after  the  manner  already 
described  (p.  758),  and  the  operation  is  finished ;  a  Y-shaped  scar  results 
(Fig.  175).  If  antiseptic  precautions  have  been  carefully  carried  out, 
no  suppuration  takes  place  along  the  track  of  the  sutures, 
and  these  may  be  left  untouched. 

(iv.)  Operations  for  Cystocele,  Urethrocele,  Prolapse 
of  the  Urethral  Mucous  Membrane,  and  Enterocele. 

(a)  Cystocele.  —  Whether  the  prolapsed  anterior 
vaginal  wall  carry  down  the  posterior  bladder  wall  or 
not  the  operative  treatment  is  the  same;  namely,  by 
anterior  colporrhaphy,  already  described  (p.  757),  or  by 
a  special  method  devised  by  Stoltz  of  Nancy. 

The  instruments  necessary  are  a  No.  8  male  bladder 
sound,  two  tenacula,  hooked  forceps,  sharp-pointed  angu- 
lar scissors,  half-curved  needles,  and  a  holder  (Spencer 
Wells'  or  Hagedorn's  according  to  the  kind  of  needle 
used).  Fine  carbolised  silk  is  preferable  for  the  suture. 
The  parts  are  best  exposed  by  means  of  a  Sims'  specu- 
lum and  a  silver  wire  passed  through  the  cervix  (.r),  by 
of  superimposed  j^^paus  of  which  tractiou  downwards  and  backwards  may 

suture     passed;  l    i.         1 

operation   com-  be  excrtcd.     Four  poiuts  must  be  selected  :  two  lateral 
P'''""-  (Fig.  176.  1  1,\  fixing  the  external  lioundarics  of  the  sur- 

face to  be  bared,  one  behind  the  urethral  orifice  (2),  and  another  in  front 
of  the  cervix  (3) :  these  four  points  should  be  capable  of  fairly  close 
approximation.    They  are  united  by  curved  incisions,  so  that  the  space  to 


Fig.  175. —  3rd  staiie. 
Superficial  layer 


762 


SYSTEM   OF  GYNECOLOGY 


be  denuded  is  almost  circular  iu  shape  (/).     The  sound  is  now  passed 

into  the  bladder,  and  the  mucous  membrane  of  the  vagina  kept  on  the 

stretch  by  pressure  of  its  point.      Denudation 

should  be  performed  in  the  usual  "way  with  knife 

or  scissors,  the  sound  being  used  as  a  guide  and 

a  resistant  body.    As  a  rule  no  bleeding  requires 

attention.     The  needle  being  threaded,  its  point 

is  inserted  on  the  right  (operator's)  side  of  the 

urethral  orifice,  and  slightly  below  it.     It  passes 

beneath  the  mucous,  and  appears  upon  the  raw 

surface ;  is  again  introduced  on  the  mucous,  and 

again  made  to  come  out  on  the  denuded  surface. 

This  manoeuvre  is  repeated  all  round  the  edge 

of  the  wound,  and  finally  the  thread  brought  out 

on  the  left  (operator's)  side  of  the  urethra  and 

below  it  (Fig.  176).    Traction  is  then  made  upon 

the  two  ends  of   the  suture  at   the  same  time 

Fig.  176.— stoitz's  operation  for   that  the  souud  (now  removccl  from  the  bladder) 

iZ'tt,  -'iSZlfZ:^.   is  ^sed  to  push  in  the  projecting  cystocele.    The 

ment  for  tenacuia  before   edges  of  the  denuded  sui'face  are  by  this  means 

urethral oHiice-a'.'cervLx,^^    drawn  together  and  the  prolapsed  bladder  wall 

wire  or  tenaculum;  a,  anus,    rcstored  to  its  uomial  situation.     Ou  tying  the 

ends  of  the  silk  suture,  the  site  of  the  operation  will  be  marked  by  a 

pouch-like  cicatrix.     The  urine  should  be  drawn  off  every  six  or  eight 

hours,  and  the  suture  withdrawn  about  the  tenth  day. 

This  method  is  of  great  value  when  combined  with  Martin's  or  Hegar's 
colpoperineorrhaphy  for  the  treatment  of  cystocele  and  rectocele.  It 
results  in  a  very  firm  circular  cicatrix,  and  requires  very  little  manual 


d 


dexterity  for  its  performance. 

The  objection  to  Stoltz's  method  is  that 
his  operation  tends  to  draw  the  cervix 
downwards ;  hence  with  a  uterus  pro- 
lapsed in  a  state  of  ante-version  it  would 
tend  to  aggravate  the  condition. 

ifi)  In  urethrocele  there  is  a  localised 
dilatation  of  the  urethra  in  its  middle 
third,  the  neck  of  the  sac  being  more  or 
less  constricted.  A  certain  amount  of 
urine  collects  in  this  sac,  and  becomes 
alkaline  or  putrid  (Fig.  177). 

The  sac  should  be  opened  by  means 
of  the  scissors,  or  Pacquelin's  cautery,  and 
allowed  to  drain  until  the  parts  are  in  a 
more  healthy  condition :  a  very  simple  plastic  operation  can  then  be 
carried  out,  the  edges  of  the  wound  being  denuded  and  brought  together 
by  a  deep  and  superficial  set  of  interrupted  sutures. 

(y)  Prolapne  of  the  urethral  mucous  membrane  is  recognised  by  the 


Fio.  177.  —  Urethrocele  ;  lateral  view  in 
section,  a,  Vaginal  surface  of  sac ; 
h,  urethra ;  c,  cavity  of  urethro- 
cele;  d,  bladder;  e,  anterior  wall 
of  urethra  ;  /,  posterior  wall. 


PLASTIC   GYNECOLOGICAL    OPERATIONS  763 

appearance  at  the  meatus  of  a  swelling  of  deep  red  colour,  easily 
reducible. 

Emmet's  operation  for  the  cure  of  this  displacement  is  as  follows : 
The  patient  is  placed  in  the  left  lateral  position,  and  a  Sims'  speculum 
inserted  into  the  vagina;  a  button-hole  longitudinal  slit  one  and  a  half 
inches  long  is  made  into  the  urethra,  and  through  this  orifice  from 
before  backwards  the  redundant  prolapsed  portion  of  mucous  membrane 
is  drawn  with  a  tenaculum.  This  is  held  by  an  assistant  in  the  wound 
while  a  large-sized  metal  bladder  sound  is  passed  into  the  urethra,  so  as 
to  smooth  out  the  lining  membrane  and  push  it  towards  the  neck  of  the 
bladder. 

Sutures  should  now  be  passed  through  the  flaps  of  the  wound 
transversely,  and  in  such  a  manner  as  to  transfix  the  drawn-through 
lining  membrane ;  the  excess  of  this  tissue  is  now  cut  away,  and  the 
opening  brought  together  by  means  of  interrupted  carbolic  silk  sutures. 

(8)  Vaginal  enterocele  may  be  either  anterior  or  posterior ;  the  anterior 
is  so  rare  that  it  may  be  neglected.  In  posterior  vaginal  enterocele  the 
intestines  are  forced  down  between  the  anterior  rectal  and  posterior 
vaginal  walls :  as  a  consequence  a  large  mass  is  found  projecting  like  a 
rectocele.  The  cervix  and  uterus,  however,  remain  in  their  normal 
situation.  The  patient  being  anaesthetised,  and  in  the  dorsal  position,  a 
volsella  is  attached  to  the  posterior  lip  of  the  cervix,  and  some  traction 
downwards  and  forwards  is  used ;  a  space  is  then  denuded  on  its  pos- 
terior surface,  and  a  corresponding  one  on  the  posterior  vaginal  wall; 
these  raw  surfaces  are  then  sutured  by  means  of  carbolic  silk  in  the 
usual  manner,  after  reduction  of  the  intestine. 

(v.)  Amputation  of  the  cervix  may  be  necessary  for  either  supra- 
vaginal or  infravaginal  hypertrophy. 

Supravaginal  hyijertrophy  of  the  cervix  is  essentially  a  hypertrophy 
of  the  cervix  above  its  insertion  into  the  vagina;  it  occurs,  as  a  rule,  in 
nulliparous  women.  The  uterus  is  increased  in  weight  which  causes  pro- 
lapse ;  it  should  be  noted  that  in  this  variety,  as  the  uterus  descends, 
prolapse  of  the  upper  part  of  the  vagina  takes  place  first,  whereas  in  pro- 
lapsus uteri  of  the  multiparous  Avoman,  rectocele  and  cystocele  appear 
and  precede  the  uterine  prolapse. 

Infravaginal  hypertrophy — or  more  properly  "  elongation  " — may  occur : 

1.  As  a  complication  of  prolapsus  uteri,  when  indeed  it  is  apparent 
only :  reduction  of  the  displacement  usually  results  in  a  disappearance 
of  the  hypertrophy. 

2.  As  a  congenital  condition. 

Amputation  of  an  apparently  elongated  cervix  in  prolapsus  uteri  is 
rarely  justifiable,  but  in  the  congenital  form  a  plastic  operation  is  cer- 
tainly indicated  (vide  p.  769). 

(vi.)  Vaginal  fixation  (Hysteropexy)  consists  in  fixing  the  retro- 
verted  fundus  in  a  forward  or  anteverted  position  by  suturing  it  to  the 
anterior  vaginal  cul-de-sac. 

This   operation,  which  was  originated  by  Shucking,  has  been  im- 


764 


SYSTEM  OF  GYNAECOLOGY 


proved  by  Duhrssen,  and  modified  in  some  of  its  minor  details  by 
Mackenrodt. 

D'dhrssens  Oj^eration.  —  The  patient  being  under  the  influence  of  an 
anaesthetic -is  placed  in  the  dorsal  position,  with  knees  supported  and 
kept  apart  by  a  Clover's  crutch.  The  genitalia  are  thoroughly  cleansed 
■with  1  in  1000  mercurial  solution,  and,  after  inserting  a  Sims'  speculum, 
the  vaginal  mucous  membrane  is  carefully  rubbed  over  with  cotton  wool 
dipped  in  the  same  mixture. 

The  anterior  lip  of  the  cervix  is  now  seized  with  a  volsella,  and  the 
uterus  dragged  down  as  low  as  possible ;  the  uterine  cavity  is  slightly 
dilated,  and  then  scraped  Avith  a  sharp  flushing  curette  :  possible  con- 
tamination of  the  uterine  sutures  to  be  passed  later  is  thus  avoided.  If 
the  cervix  be  much  hypertrophied  it  is  amputated,  as  a  large  cervix 
tends  to  prevent  the  uterus  remaining  in  a  position  of  anteversion. 

A  superficial  transverse   incision  is 

_,g        made  with  a  scalpel  at  the  insertion  of 

the  anterior  vaginal  wall  into  the  cervix ; 

with   scissors   and    the   forefinger,    the 

^ JSy,„?/^  .--"""•-,  \2ifliifl<- d    cellular  tissue  (Fig.  178,  rtf7J  between  the 

(sr— ---!^         ^"^^8^ ^'    bladder  and  cervix  is  broken  down  until 

■1  ^i/*-';/^^^      the  peritoneum  lining  the  utero-vesical 

pouch  is  reached.    The  peritoneal  cavity 
/  is  now  opened  and  the  edges  sewn  to 

Fig.  178.- Va-inal  fixation  ;  transverse  and     thoSC  of  the  Vagiual  WOUud. 

somewhat  oblique    section    above   the  a    -nt       o      -i  ^  i_i      i_ 

level  of  the  internal  os  uteri.    11,,  A  JN  o.  8  Silver  male  Catheter  IS  now 

Temporary  uterine  suture  ;  2  2    suture    passed  illtO  tllC  UterUS,  and  by  meauS  of 
including  vag-inal  flaps,  rt «,,  and  uterme    ^  '     .     .       "^ 

wall;  this  is  tied  at  x;  0,  anterior  the  usual  ioMr-ae-?>iai^re  it  IS  antevcrtcd  ; 
vaginal  cu;-rfe-«ac;d£?„  cellular  tissue  jgy  p^-essure   backwards   of  the   handle 

in  front  of  uterus ;    c,   catheter  in  «,       J    i 

uterine  cavity;    u,    uterine   body;    ./,     the   fuudus,  COVercd  by  the   peritonC-Um, 

'^''"^'*®'''  appears  at  the  incision  wound.      With 

a  handled  needle  provided  with  a  rectangular  curve,  a  stout  carbolised 
silk  suture  or  silkworm  gut  stitch  is  passed  through  the  anterior  wall 
of  the  uterine  fundus  as  high  up  as  possible,  the  vaginal  flaps  not  being, 
however,  included ;  the  ends  of  the  suture  are  given  to  an  assistant, 
Avho  exerts  traction  downwards,  allowing  of  the  introduction  of  two  or 
more  further  sutures  into  the  anterior  wall  higher  up  than  the  first ;  the 
lust  should  pierce  the  uterus  at  the  level  of  the  catheter  point  (Fig.  178, 
1  Ij.     These  are  temporary,  for  traction  only. 

Three  sutures  should  now  be  passed  one  above  the  other  through  the 
uterine  wall,  but  including  the  edges  of  the  vaginal  flaps  (2  2^).  The 
temporary  ligatures  may  now  be  removed  and  the  permanent  ones  tied  ; 
a  superficial  continuous  suture  may  be  inserted  to  obtain  an  accurate 
adaptation  of  the  flaps. 

The  uterus  will  now  be  felt  in  a  state  of  anteversion.  After  washing 
out  the  uterine  cavity  with  an  antiseptic  solution  the  vagina  must  be 
packed  with  iodoform  gauze. 

The  patient  should  bo  k(;pt  at  absolute  rest  for  fourteen  days,  and 


PLASTIC    GYNECOLOGICAL    OPERATIOXS  ■]6<i 

have  a  ring  pessary  inserted  before  getting  up.  The  value  of  this 
proceeding  is  still  uncertain.  The  three  dangers  of  the  operation  are  — 
(i.)  cutting  one  or  both  ureters  ;  (ii.)  wounding  the  bladder  ;  (iii.)  haemor- 
rhage from  the  vaginal  flaps.  Two  after-effects  must  be  taken  into  con- 
sideration ;  namely,  a  certain  irritability  of  the  bladder  and  a  tendency 
to  miscarriage,  owing  to  the  fixation  of  the  anterior  uterine  wall  to  the 
vagina.  It  has  been  denied,  however,  by  many  that  either  of  these 
sequels  are  met  with.  Diihrssen  has  recently  published  statistics  of 
197  cases  with  one  death  (about  0-5  per  cent). 

AlackenrocW s  Modification.  —  This  operator  does  not  consider  it  neces- 
sary to  open  the  peritoneum  in  the  anterior  cul-de-sac,  and  is  strongly 
opposed  to  fixing  the  uterus  by  carbolic  silk  suture  or  silkworm  gut 
stitch;  he  transfixes  the  body  of  the  uterus  in  preference  to  the  fundus 
only,  and  also  prefers  a  longitudinal  vaginal  incision. 

The  advantages  claimed  for  this  method  are  —  1.  That  the  longitudi- 
nal incision  does  away  with  the  risk  of  injury  to  ureters  or  bladder,  and 
again  that,  where  the  vagina  is  roomy,  and  the  walls  lax,  this  incision 
can  be  converted  into  a  rhomboidal  one ;  thus  an  anterior  colporrhaphy 
can  be  carried  out,  which  strengthens  the  point  of  attachment  of  the 
uterus.  2.  That  by  using  absorbent  catgut  the  uterus  is  maintained  in 
place  purely  by  adhesions,  which  in  the  event  of  pregnancy  ensuing  are 
capable  of  being  stretched ;  repeated  miscarriage  after  this  operation  is 
thereby  avoided  (Webb). 


C.  OPERATIONS  FOR  LACERATIONS  OF  THE  CERVIX  (nOT  RECENT)  THE  RE- 
SULT OF  PARTURITION  (eMMEt's  OPERATION  OR  TRACHELORRHAPHY 
AND  ITS  modifications) 

If  the  cervix  of  a  woman  who  has  been  confined  at  least  two  months 
be  exposed  by  means  of  a  Sims'  speculum,  one  or  more  of  the  following 
conditions  may  be  observed  :  — 

(a)  The  cervix  may  be  normal,  with  the  exception  of  two  lateral 
notches  more  or  less  marked. 

(y8)  The  anterior  and  posterior  lip  may  be  separated  by  one  or  two 
lateral  rents  extending  to  the  vaginal  roof. 

(y)  One  or  two  lateral  lacerations  may  be  present  as  before,  but  in 
addition  considerable  extroversion  of  the  cervical  mucous  mem- 
brane ;  the  uterus  will  be  probably  subinvoluted,  and  the  patient 
suffering  from  menorrhagia,  leucorrhoea,  backache,  and  reflex 
disturbances.  If  a  tenaculum  be  applied  to  the  outer  surface 
of  each  lip,  and  the  two  approximated,  the  extroversion  dis- 
appears, and  the  rent  becomes  more  apparent. 

(8)  The  anterior  lip  may  be  torn  through  from  front  to  back,  the 
posterior  being  intact ;  or  the  reverse  obtains,  the  posterior  lip 
only  being  injured.  Extroversion  may  or  may  not  complicate 
either  of  these  injuries. 


766  SYSTEM   OF  GYNAECOLOGY 

(e)  The  lacerations  may  be  arranged  in  a  stellate  form  and  of  varying 
depth. 

Of  these  varieties  none  but  those  included  under  the  headings  (y)  and 
{^)  require  operation,  and  then  only  ^vhen  extroversion  is  present.  Until 
recently  it  was  considered  that  there  was  a  direct  relation  between  cer- 
vical lacerations  and  cancer ;  but  so  far  no  affirmative  evidence  has  been 
adduced  in  support  of  this  surmise.  It  is  therefore  obvious  that  the 
necessity  for  the  performance  of  this  operation  does  not  frequently 
arise. 

Operation  when  there  is  a  simple  deep  bilateral  laceration  with 
extroversion. 

Preliminary  Treatment.  —  Vaginal  injections  of  hot  water  (110°  F.) 
should  be  used  night  and  morning  for  a  month  or  six  weeks  before  the 


Fig.  179.  —  Emmet's  scissors  (left  angular). 


Operation,  and  during  this  time  the  patient  should  be  in  the  recumbent 
position.  By  their  means  local  congestion  is  relieved,  and  the  loss  of 
blood  at  the  operation  from  the  denuded  surfaces  is  much  less.  Should 
there  be  any  cicatricial  tissue  at  the  base  of  the  broad  ligament  in  con- 
nection with  either  laceration,  the  corresponding  fornix  should  be  painted 
once  every  seven  days  with  strong  lin.  iodi.  The  temperature  should 
be  normal  night  and  morning,  the  urine  free  from  albumin  and  sugar, 
and  the  general  health  of  the  patient  good;  it  must  be  ascertained  that 
tliere  is  no  possibility  of  existing  pregnancy. 

Actual  Operation. — The  instruments  required  are :  A  Sims'  specu- 
lum; volsellas  and  tenaculums;  long-handled  angular  bladed  knives 
(right  and  left) ;  Emmet's  scissors  (right  and  left),  angular  (Fig.  179) 
and  angular  and  curved  (Fig.  180) ;  needle  holder ;  short  stout  needles, 
with  sharp  triangular  points,  straight  or  very  slightly  curved ;  two  sizes 
of  silver  wire;  carbolised  silk  suture  (medium  thickness). 

If  necessary  the  operation,  which  is  painless,  may  be  performed 
without  general  anassthesia,  local  injections  of  a  cocaine  solution  into 
the  cervix  being  all  that  is  requisite. 

If  a  general  anaesthetic  be  preferred,  the  patient,  being  brought  under 
its  influence  and  an  antiseptic  vaginal  douche  given,  should  be  placed  in 
the  s(Mni|)rone  CSirris')  position.  The  necessary  manipulations  are  carried 
oiitiniu;h  more  easily  in  tliis  attitudo,  altliough  rc^.spiratory  effort  is  some- 
what interfered  with.  Some  operators  prefer  the  dorsal  decubitus  as 
giving  more  space,  but  this  is  open  to  doubt. 


PLASTIC   GYNAECOLOGICAL    OPERATIONS 


767 


As  subinvolution  is  almost  invariably  present,  it  is  considered  advisa- 
ble to  commence  the  procedure  by  diglit  cervical  dilatation  and  curettage  ; 
it  takes  but  a  few  more  minutes,  and  is  of  great  benefit  to  the  patient. 


Fig.  180.  —  Emmet's  scissors  (ang-ular  aod  curved). 


Having  performed  this  with  a  flushing  curette,  introduce  the  Sims' 
speculum  (Fig.  181,  S)  and  expose  the  cervix.  A  piece  of  stout  silver 
wire  (lo,)  should  be  passed  deeply  through  the  anterior  lip  (aj.  By  means 
of  this  steady  traction  can  be 
made  downwards,  and  the 
uterus  kept  firm  while  denuda- 
tion and  suturing  are  carried 
out. 

If  there  be  marked  extro- 
version, with  hypertrophy  of 
the  cervical  glands,  and  the 
parts  bleed  easily  on  handling, 
erasion  by  means  of  the  curette 
will  make  the  subsequent  steps 
easier  of  performance. 

Having  passed  the  uterine 
sound  to  mark  the  site  of  the 
internal  os  uteri  (0  w  i),demida- 
tion  is  commenced.  The  lower 
portions  of  the  anterior  and 
posterior  lips  are  first  pared 
by  means  of  the  angular  knives 
and  scissors.  An  important 
site  which  frequently  escapes  is  the  deep  angle  of  the  laceration  on  each 
side  (Z  /,).  The  upper  portions  of  the  anterior  and  posterior  lips  may 
now  be  treated  in  a  similar  manner.  A  sufficiently  broad  strip  (a  a,)  must 
be  left  uupared  on  both  lips  to  avoid  complete  closure  of  the  cervical 
canal  when  suturing  is  carried  out.  Any  cicatrices  at  or  about  the  angles 
of  the  laceration  should  now  be  excised ;  but,  in  doing  so,  large  vessels 
may  be  opened  and  serious  haemorrhage  result.  Frequently  the  tissue 
is  extremely  hard,  and  great  patience  is  necessary  in  order  to  denude 


Fig.  181.  —  a.  Posterior  cemcal  lip;  a,,  anterior  cervical 
lip;  a  (7,,  undenuded  strip;  jr,,  stout  wire  by  which 
cervi.x  is  steadied  ;  S,  Sims'  si)eculum  (blade  in  sec- 
tion); 1 1^,  angles  of  deep  laceration  \  o  u  i,  os  uteri 
internum  ;  j(.  needle  passing-  throujjh  upper  bared 
surface  ;  *,,  double  thread,  throufrh  loop  of  which  the 
wire  suture  w  is  passed  ;  1  1,,  "2  '2,,  sutures  inserted 
but  not  tied. 


768  SYSTEM   OF  GYNECOLOGY 

the  flaps  thoroughly.  An  intermittent  antiseptic  douche  should  be  used 
during  denudation  to  wash  away  the  blood  and  to  preserve  asepsis. 

Tlie  Introduction  of  the  jSutia-es.  —  Silvered  copper  wire  of  medium 
stoutness,  and  about  12  inches  in  length,  should  be  used  for  each  suture. 
The  short,  stout  triangular  pointed  needle  (n)  is  first  doubly  threaded  with 
carbolised  silk  (sj,  so  that  a  loop  of  3  or  4  inches  in  length  is  produced. 
The  needle  and  silk  suture  are  passed,  as  in  the  upper  portion  of  the  figure, 
on  the  lower  bared  surface  in  the  direction  of  the  arrow,  the  loop  remain- 
ing suspended  from  the  point  of  entry.  The  wire  suture  (w)  is  hooked 
through  it,  and  the  needle  and  silk  are  rapidly  pulled  through  beneath 
the  raw  surface,  drawing  the  wire  in  their  track.  The  needle  is  entered 
again  at  the  edge  of  the  undenuded  strip,  and  passed  directly  outwards, 
the  same  manoeuvre  with  regard  to  the  silver  wire  being  carried  out. 
The  other  sutures  are  passed  in  a  similar  way ;  generally  three  or  four 
are  sufficient.  The  upper  bared  surface  is  treated  in  a  like  manner. 
The  stout  wire  (to,)  is  now  removed,  and  the  anterior  and  posterior  flaps 
(a,  a)  are  brought  into  apposition.  The  wires  are  twisted,  but  not  too 
tightly ;  and  the  sound  is  passed  to  test  the  patency  of  the  cervical  canal. 
The  ends  of  the  wire  sutures  may  be  cut  short  or  twisted  together, 
covered  with  protective  gauze  and  allowed  to  remain  in  the  vagina. 
The  latter  method  permits  much  easier  access  to  the  stitches  when  their 
removal  is  required. 

The  after  treatment  is  not  different  from  that  to  be  followed  after 
any  other  plastic  operation.  Vaginal  gauze  packing  is  not  necessary. 
Should  secondary  haemorrhage  occur  the  cervix  must  be  exposed  through 
a  Sims'  speculum,  and  a  suture  passed  through  that  half  from  which  the 
bleeding  is  taking  place.  On  tightly  tying  this  the  haemorrhage  will 
cease.  The  sutures  may  be  removed  on  the  tenth  day,  a  small  blunt 
hook  being  required  to  bring  the  loop  of  wire  under  the  action  of 
the  scissors.  In  a  successful  case  the  cervix  assumed  a  virgin  appear- 
ance. 

Diihrssen  describes  a  modification  of  Emmet's  operation  by  "  flap- 
splitting."  He  considers  that  a  cervical  laceration  may  be  repaired  with- 
out denudation  by  cutting  into  the  tear  at  the  line  of  junction  of  the 
cervical  raucous  membrane  and  that  of  the  portia,  the  incision  being  ^  cm. 
in  depth.  On  putting  traction  on  the  wound  edges  a  raw  surface  is 
produced,  the  upper  half  of  which  is  to  be  sutured  to  the  lower.  Another 
advantage  claimed  is  that  the  cicatricial  bands  extending  from  the  lacera- 
tion into  tiie  parametric  tissue  can  be  safely  divided. 

Should  the  tear  of  the  cervix  have  extended  into  the  parametric 
tissue  a  cicatrix  results,  which  draws  over  the  uterus  to  the  affected  side. 
Severe  pain  may  be  caused  by  this  condition,  and  Martin  has  proposed 
and  carried  out  a  plastic  operation  for  its  relief.  The  patient  being 
anaesthetised,  and  in  either  the  dorsal  or  left  lateral  position,  the  uterus 
is  pulled  over  from  the  affected  side,  and  a  semilunar  antero-posterior 
incision  made  over  the  base  of  the  broad  ligament,  following  the  line  of 
the  cervix.     Tlie  anterior  and  postcu-ior  extremities  of  the  wound  are 


PLASTIC   GYNECOLOGICAL    OPERATIONS  769 

brought  together   by   sutures,  so   that   a   transverse   cicatrix   results. 
Martin  reports  excellent  results  from  this  method. 

D.  OPERATIONS  FOR  CERTAIN  CERVICAL  DEFORMITIES  AND  IXFLAMMATION.S 

Cervical  deformities  requiring  operation  include  stenosis  of  the  os 
uteri  externum  and  infravaginal  hypertrophy ;  in  chronic  and  intractable 
inflammation  of  the  mucous  membrane  of  the  cervical  canal  resort  to  the 
knife  is  sometimes  also  necessary. 

1.  For  stenosis  of  the  os  uteri  externum,  when  associated  with  a  coni- 
cal cervix,  Marckwald  has  introduced  a  flap  operation  which  will  be 
described  in  the  next  paragraph.  In  Germany  and  America  it  has  met 
with  considerable  favour,  but  in  England  simple  bilateral  incision  has 
been  deemed  sufficient. 

2.  In  hypertrophy  of  the  vaginal  portion  there  is  no  thickening  of  the 
mucous  and  underlying  tissues,  hence  the  diameter  of  the  cervix  is  not 
increased.  On  examination,  the  anterior  and  posterior  fornices  are  in 
their  normal  situation,  and  the  fundus  uteri  is  found  at  its  proper  level 
in  the  pelvis ;  the  sound  may  pass  from  4  to  6  inches  into  the  canal  of 
the  cervix.  The  os  uteri  externum  is  frequently  very  small.  For  the 
treatment  of  this  condition  nothing  avails  but  removal  of  the  hyper- 
trophied  portion ;  many  methods  have  been  recommended  for  this  pur- 
pose, of  which  three  have  been  selected  for  description. 

(i.)    Conoidal  excision  (Sims). 

(ii.)    Circular  amputation  (Hegar). 

(iii.)   Wedge-shaped  excision  of  each  lip  (Marckwald). 

A  modification  of  ii.  and  iii.  is  advocated  by  A.  E.  Simpson. 

Sims  excised  a  cone-shaped  portion  of  the  cervix,  and  sutured  the 
vaginal  and  cervical  mucous  membranes  together. 

Hegar  has  fully  described  his  technique  in  his  Avork.  The  patient 
being  ansesthetised  and  in  the  dorsal  position,  the  cervix  is  pulled  down 
by  a  volsella  and  amputated  with  knife  or  scissors,  the  cut  being  directly 
transverse  to  the  long  axis  of  the  hypertrophied  organ ;  a  certain  amount 
of  shrinkage  of  the  stump  takes  place,  producing  an  inversion  of  the 
vaginal  mucous  membrane  (Fig.  182  A,  a).  A  raw  surface  remains,  over 
which  the  vaginal  and  cervical  mucous  membrane  must  be  united  by  sut- 
ures. These  are  passed  in  the  following  manner :  a  short  straight  needle, 
double-threaded  with  a  loop  of  carbolised  silk,  is  passed  from  the  vaginal 
mucous  membrane  (beneath  the  raw  surface  of  the  stump)  to  that  of  the 
cervix  (c)  in  the  direction  of  the  arrows,  and  then  brought  back  over  the 
surface  (Fig.  182  A,  1  1^).  Into  this  loop  is  hooked  a  piece  of  silver  wire 
about  10  inches  long,  and  by  means  of  the  silk  pulled  through  the  stump, 
which  thus  takes  the  place  of  the  original  suture :  a  series  of  these  ai-e 
passed  and  arranged  in  a  radiating  manner  (1 1,,  2  2^,3  3,),  and  the  wire 
loops  are  twisted  so  as  to  secure  accurate  adaptation  and  union  by  first 
intention  (Fig.  182  B).  The  patient  should  remain  in  bed  for  fourteen 
days,  and  the  sutures  are  best  removed  on  the  tenth  day. 

3d 


770 


SYSTEM  OF  GYNECOLOGY 


ITarckicald's  method,  which  is  a  modification  of  Simon's,  has  been  in 
general  use  in  Germany  since  the  publication  of  his  original  paper  on  the 


(A) 


(B) 


Fia.  182.  — Amputation  of  cervix  (Hegar).  (A)  Mode  of  passage  of  sutures  ;  a,  inverted  vaginal  mucous 
membrane  ;  b,  cervix  ;  c,  cervical  canal  in  section  ;  d,  raw  surface  of  stump.  (B)  Sutures  tied  ; 
letters  and  figures  as  in  A. 

subject.  The  cervix  is  split  into  an  anterior  and  posterior  lip  by  means 
of  scissors  or  the  knife  (Fig.  183  A,  a  b),  and  out  of  each  is  excised  a 
wedge-shaped  piece  leaving  a  deep  groove  (Fig.  183,  A,  c  c  c^  c,,  B,  c  c^), 
bounded  by  an  anterior  (B,  d  d,)  and  posterior  (B,  e  e^  flap,  front  and 


Anterior 


Anterior 


Fig.  188.  —  Amputation  of  tho  cervix  (Marckwald's  method).  (A)  Surface  view,  ah,  Incision  dividing 
cervix  Into  anterior  and  posterior  lips,  In  each  of  which  Is  a  wqdge-shaped  groove,  a  c,  c,  c,.  Tlio 
direction  and  mode  of  passage  of  two  sutures  is  shown.  (15)  Side  view.  Tho  dotted  outline  indi- 
cates tho  original  dimensions  of  the  cervix  A  h,ff,  anterior  and  posterior  fornix  \  d  e,,(l ,  «,,  anterior 
and  posterior  flaps  of  anterior  and  posterior  lijis  of  cervix  respectively  ;  c  <•,,  as  in  A. 

l)ack  ;  the  cervical  surface  of  each  is  united  to  the  corresponding  vaginal 
surface  by  a  series  of  sutures  which  are  passed  as  shown  in  the  diagram. 
The  sound  should  be  passed  to  ascertain  if  the  cavities  of  cervix  and 
body  together  do  not  exceed  2\  to  3  inches. 


PLASTIC   GYNAECOLOGICAL    OPERATIONS  771 

The  advantages  of  this  operation  appear  to  be  that  it  is  almos.t 
entirely  free  from  clanger ;  no  after  bleeding  can  take  place  and,  as  a 
I)atent  external  os  uteri  is  produced,  it  is  of  much  value  in  stenosis ; 
lastly,  the  technique  is  very  simple  and  convalescence  is  rapid. 

Simpson  of  Edinburgh  introduces  the  sutures  before  amputating  the 
hypertrophied  cervix,  the  needle  being  passed  through  the  whole  thick- 
ness of  the  organ.  After  removing  the  mass  each  stitch  is  cut  in  two  at 
the  site  of  the  cervical  canal,  and  the  stump  treated  as  in  Hegar's  method. 
There  are  manifest  advantages  in  this  method:  "It  is  easier  to  pass  the 
needle  through  the  dense  tissue  when  the  cervix  is  fixed  with  the  vol- 
sella;  the  sutures  serve  as  a  means  of  traction  when  the  portion  grasped 
by  the  volsella  has  been  cut  away."  Ligatures  can  be  tied  immediately 
the  flaps  have  been  made  by  amputation  (Hart  and  Barbour). 

If  the  sutures  are  of  silver  wire  they  should  be  removed  in  about  ten 
days'  time  by  means  of  a  Sims'  speculum,  a  rake  (a  blunt  bent  probe)  to 
bring  the  embedded  sutures  into  view,  and  a  pair  of  scissors. 

The  removal  of  a  hypertrophied  cervix  by  an  ecraseur  or  galvano- 
caustic  wire  is  not  to  be  recommended. 

3.  In  certain  cases  of  intractable  cervical  catarrh,  it  is  a  legitimate 
proceeding  to  excise  the  mucous  membrane  lining  the  cervix. 

iSchroeder's  method  consists  in  drawing  down  the  cervix  by  means 
of  two  tenacula,  one  being  attached  to  each  lip;  it  is  then  divided 
bilaterally  with  knife  or  scissors,  the  incision  being  carried  up  to  the 
vaginal  fornix.  A  transverse  incision  is  made  at  the  base  of  each  lip, 
and  as  high  as  can  be  reached,  cutting  right  through  the  mucous  mem- 
l)rane  \^vide  Figs.  46,  47,  p.  202,  in  Dr.  Barbour's  paper,  "  Inflammation 
of  the  Uterus"].  The  point  of  the  knife  is  next  entered  at  c,  and  the 
l)lade  passed  up  to  join  the  deeper  part  of  incision  a.  A  large  piece  of 
mucous  membrane  is  thus  excised ;  the  same  manoeuvre  is  carried  out 
on  the  other  side.  The  points  a  and  c  are  brought  together  by  sutures. 
The  lower  and  middle  portions  of  the  cervical  canal  are  now  lined  by 
vaginal  mucous  membrane. 

Martin  combines  this  with  amputation  of  the  cervix  in  his  method 
of  treating:  these  cases. 


Y..     OPERATIONS     FOR     REPAIR     OF     FISTULOUS     OPENINGS     BETWEEN    THE 
BLADDER    OR    INTESTINE    OR    OTHER    VISCERA 

It  Avill  be  convenient  to  subdivide  fistulas  into  those  in  which  the 
chief  symptom  is  an  involuntary  escape  of  urine  through  the  vagina 
(urinary)  and  those  in  which  intestinal  contents  are  similarly  passed 
(f  cecal). 

Urinary  Fistulas.  —  The  septum  between  the  genital  and  urinary 
channels  may  have  its  continuity  destroyed  in  various  situations ;  any 
artificial  communication  thus  produced  between  two  organs  is  called  a 
fistula.     The  varieties  of  urinarv  fistulas  are  six  in  number,  and  are 


772  SYSTEM  OF  GYNECOLOGY 

named  according  to  the  organs  between  which  an  artificial  opening 
occurs  :  1.  Urethro-vaginal ;  2.  Vesico-vaginal ;  3.  Vesico-utero-vaginal 
(jiixta-cervical) ;  4.  Vesico-uterine,  cervical,  corporeal ;  5.  Uretero-vagi- 
nal;    6.  Uretero-iiterine. 

A  rare  condition  in  which  the  intestine  (small  or  large)  opens  into 
the  bladder,  and  faeces  are  passed  with  the  urine,  constitutes  an  entero- 
vesical  fistula. 

Of  urinary  fistulas,  by  far  the  most  frequent  is  the  vesico-vaginal ; 
it  is  due  either  to  direct  injury  to  the  vesico-vaginal  wall  during  labour, 
or  to  a  sloughing  of  the  same  subsequently,  owing  to  prolonged  impaction 
of  the  foetal  head.  An  ulcerated  opening  may  result  from  a  vesical  cal- 
culus. This  variety  of  fistula  frequently  complicates  the  extension  of 
malignant  disease  from  the  uterus  to  the  bladder  wall,  and  is  artificially 
produced  as  a  means  of  cure  for  chronic  cystitis  (Emmet's  operation). 

The  urine  dribbles  away  involuntarily,  in  a  more  or  less  continual 
stream ;  and  the  passage  of  the  catheter  gives  a  negative  result.  An 
exception,  however,  is  found  in  those  cases  in  which  the  opening  exists 
above  the  orifices  of  the  ureters  ;  the  patient  then  has  a  more  or  less 
considerable  retentive  power  when  in  the  erect  position.  Incontinence 
occurs  immediately  after  labour,  when  the  accident  is  due  to  the  forceps 
or  version ;  if  it  be  not  noticed  until  a  few  days  subsequently  it  is  due 
to  sloughing  of  the  parts  pressed  upon. 

In  urethro-vaginal  fistula  the  urine  is  retained  in  the  bladder,  but 
passed  in  a  stream  through  the  lower  portion  of  the  vagina.  In  uretero- 
genital  fistula  urine  is  voided  voluntarily  at  the  usual  times,  and  if  the 
catheter  be  passed  into  the  bladder  a  certain  amount  of  secretion  (but 
not  so  much  as  usual)  is  drawn  off ;  the  vagina  will  at  the  same  time  be 
found  moistened  with  urine.  This  accident  may  be  a  sequel  of  total 
extirpation  of  the  uterus.  It  will  be  most  convenient  to  describe  (I.)  the 
operative  treatment  of  vesico-vaginal  fistula;  and  next  (II.)  the  more 
complicated  varieties. 

I.  Vesico-vaginal  Fistula.  —  As  this  lesion  is  most  frequently  the  re- 
sult of  prolonged  pressure  during  parturition  its  situation  will  necessarily 
depend  upon  the  point  at  which  this  pressure  was  most  strongly  exerted ; 
hence  it  is  usually  found  in  the  median  line  and  behind  the  symphysis 
pubis.  If,  however,  at  the  time  of  labour  the  bladder  were  distended, 
and  therefore  above  the  symphysis,  the  solution  of  continuity  will  be 
above  the  ureteral  orifices.  The  size  of  these  openings  varies  very  much : 
the  whole  vesico-vaginal  septum  may  be  destroyed,  producing  an  aperture 
as  large  as  the  palm  of  the  hand ;  or  the  orifice  may  be  so  small  as  to 
escape  notice,  and  admit  a  bristle  only.  The  usual  shape  is  oval  or 
elliptical ;  but  should  cicatricial  bands  in  the  vaginal  wall  be  present, 
the  edges  of  the  apei'ture  may  j)resent  every  variety  of  irregularity.  In 
the  larger  kinds  the  anterior  bladder  wall  is  protnuled  through  the 
.opening  and  may  be  covered  with  incrustations.  The  continual  flow  of 
alkaline  and  often  decomposing  urine  over  the  vaginal  walls  and  external 
genitals  produces  much  redness,  soreness,  and  swelling  of  the  parts ; 


PLASTIC   GYNECOLOGICAL    OPERATIONS  773 

urinary  concretions  may  be  formed  along  the  edges  of  the  fistula  or 
in  the  vagina.  A  urinous  and  characteristic  odour  emanates  from  the 
patient's  person.     There  is  usually  amenorrhoea. 

The  plastic  means  adopted  for  the  cure  of  this  condition  are  by :  — 

(A.)  The  interrupted  suture  directly  applied  to  the  fistulous  opening. 
(B.)  Elytroplasty.  (C.)  Occlusion  of  the  vagina  below  the  fistula  (kolpo- 
kleisis). 

(A.)  Suture.  —  Three  operators  have  each  introduced  a  method  of 
denuding  and  suturing  a  fistulous  opening  to  which  their  names  are 
respectively  given  ;  they  are  Sims,  Simon,  and  Bozeman. 

(i.)  Sims'  Method.  — This  is  chiefly  characterised  by  the  careful  pre- 
paratory treatment  of  the  patient  before  operation,  and  by  the  use  of 
silver  wire  for  sutures ;  it  is  much  in  vogue  in  England  and  xVmerica. 
A  description  of  this  procedure  may  be  given  under  four  headings :  — 

(a)  Preparation  of  the  patient.  (/3)  Denudation  or  vivifying  of  the 
edges  of  the  fistula,  (y)  Passing  and  securing  the  sutures.  (S)  After 
treatment. 

(a)  Preparation  of  the  Patient. — The  importance  of  this  measure  can- 
not be  over-estimated ;  without  it  failure  will  occur  almost  inevitably. 
Six  months  or  more  after  the  labour  is  the  earliest  time  at  Avhicli  opera- 
tive measures  should  be  adopted.  Constitutional  treatment  by  means  of 
tonics,  a  stay  at  the  sea-side,  with  a  course  of  shampooing  and  careful 
dieting,  must  be  carried  out  for  a  month  or  six  Aveeks.  Hegar  and 
Kaltenbach  think  six  to  eight  weeks  after  the  labour  is  the  best  time 
for  operation.  Much  care  and  patience  are  necessary  in  the  local  manage- 
ment of  such  a  case.  The  chief  object  to  be  attained  is  a  healthy  con- 
dition of  the  edges  of  the  fistula,  which  are  frequently  inflamed,  thickened, 
and  covered  by  urinary  deposits,  usually  phosphatic  in  nature.  These 
deposits  should  first  of  all  be  removed  by  means  of  a  soft  sponge,  and  the 
raw  surface  brushed  over  with  a  weak  solution  of  silver  nitrate.  Frequent 
hot  vaginal  douches  and  hip  baths  should  be  administered,  and  the  parts 
carefully  dried  afterwards.  The  vaginal  mucous  membrane  and  vulva 
are  then  best  smeared  freely  with  vaseline  to  protect  them  from  the 
action  of  the  irritating  xirine.  The  napkins  used  by  the  patient  must 
be  thoroughly  washed  free  of  the  urine  with  which  they  are  saturated, 
and  not  sim})ly  dried. 

So  long  as  the  phosphatic  condition  of  the  urine  is  present  no  local 
improvement  Avill  take  place,  hence  it  is  desirable  to  produce  acidity, 
and  the  following  prescription  is  best  adapted  for  that  purpose :  Acid, 
benzoici  3j.,  Acid,  borici  3iss-3ij.,  Aq.  Svj. ;  y^th  part  in  water  three 
times  daily. 

When  a  state  of  acidity  is  attained  the  dose  may  be  reduced  to  such 
a  quantity  as  to  just  keep  the  urine  acid ;  too  long  a  continuance  of  the 
larger  dose  is  apt  to  produce  gastric  disturbance. 

Vaginal  cicatrices,  besides  the  pain  to  which  they  give  rise,  often  ob- 
struct the  view  and  treatment  of  the  fistula,  the  introduction  of  sutures 
being  rendered  impossible  thereby.    These  should  be  severed  by  scissors 


774 


SYSTEM   OF  GYNAECOLOGY 


in  preference  to  the  knife,  as  the  haemorrhage  is  less.  A  Sims'  glass 
vaginal  tube  is  then  passed  into  the  vagina  to  prevent  reunion  of  the 
raw  surfaces,  and  it  may  be  worn  a  few  hours  daily  ;  when  it  is  removed 
the  douche  is  to  be  given.  Pressure  applied  in  this  manner  frequently 
results  in  an  absorption  of  the  cicatricial  tissue. 

For  the  operation  an  anaesthetist,  three  assistants,  and  a  nurse  are 
requisite ;  one  nurse  will  hold  the  Sims'  speculum  and  elevate  the  right 
buttock,  another  will  sponge  and  hand  the  instruments.  The  use  of 
chloroform  is  advantageous  in  that  it  permits  free  access  to  the  parts  ; 
the  actual  pain  of  the  operation  itself,  however,  is  trifling. 

The  following  instruments  are  necessary :  A  Sims'  speculum ;  two 
flat  spatulas ;  three  long-handled  knives,  one  with  a  long  haft  and  a 
short,  straight,  narrow  blade,  the  other  two  with  angular  blades  (right  and 


Fig.  184.  — Vesico-vaginal  fistula  knives  (Sims'). 


left)  (Fig.  184) ;  two  long-handled,  sharp-pointed,  curved  scissors  (right 
and  left) ;  uterine  hook  (Emmet's)  for  making  counter  pressure  (Fig. 


Fig.  I5.J.  —  L'terine  hooli  (Emmet's)  for  making  counter  pressure. 

185) ;  wire  adjuster  (Fig.  186);  volsella  and  tenaculum  ;  Spencer  Wells' 
forceps ;    long   toothed   forceps ;    six    sponge   holders   for   very   small 


P'iG.  180.  — Wii'c  adjuster. 


sponges ;  needle  holder  and  curved  needles  (from  |-  to  1  in.  long)  with 
points  not  too  sharp  and  cutting;  silver  wire  and  carbolic  silk  sutures; 
two  sigmoid  TS-shaped)  catheters. 

(fj)  iJt'ii/ndation.  — The  patient  is  placed  in  the  left  semiprone  position. 
The  fistula  is  thoroughly  exposed,  and  a  strong  light  thrown  on  to  the 
site  of  operation  by  means  of  Sims'  speculum;  if  necessary  the  cervix  may 
be  pulled  downwards  and  backwards  by  means  of  a  volsella  attached  to 
the  anterior  lip.  The  tenacula  are  applied  at  the  opposite  sides  of  the 
fistula  to  ascertain  where  the  least  traction  will  bring  the  edges  together. 


PLASTIC  GYNECOLOGICAL    OPERATIONS 


775 


This  being  ascertained,  the  highest  point  of  the  fistulous  edge  is  seized, 
either  by  long  toothed  forceps  or  a  tenaculum,  and  placed  slightly  on  the 
stretch.  By  means  of  a  straight  or  angular  bladed  knife  (Fig.  184)  a  strip 
of  mucous  membrane  is  then  removed  entire  from  the  vaginal  edge  of  the 
opening :  the  blade  of  the  knife  should  cut  in  an  oblique  direction,  and 
not  touch  the  vesical  mucous  membrane,  as  an  injury  to  it  will  inevitably 
lead  to  copious  bleeding  (Fig.  188,  A,  B).  Some  operators  use  scissors, 
and  a  combination  of  both  instruments  may  be  necessary  in  order  to 
obtain  a  raw  surface.  Any  haemorrhage  is  checked  by  the  intermittent 
hot  douche  and  the  pressure  of  small  sponges  on  holders. 


■bl 


Fig.  187. —Mode  of  freshening  the  edpes  of  a  fistula  by  "flap-splitting."  A.  Flaps  split  and  deep 
suture  passed  but  not  tied,  bl.  Bladder  mucous  membrane;  v,  vaginal  mucous  membrane.  B. 
Deep  suture  tied  and  superficial  one  passed. 

Another  mode  of  freshening  the  edges  is  by  the  process  of  dedouble- 
ment  or  flap-splitting  (Fig.  187,  A,  B) ;  it  is  useful  when  the  vagina  is 
narrow,  and  there  is  not  sufficient  redundant  tissue  to  make  satisfactory 
flaps.     The  raw  surface  is  produced  by  splitting  up  the  edges  of  the 

^  B 


■—d 


a.-i'.-c. 


Fig.  188.  —  Mode  of  passinfr  sutures  in  vesico-vafflnnl  fistula.  A.  As  seen  in  semiprone  position.  8, 
Sims'  .spociihun,  blade  in  .section  ;  c,  cervix,  secured  by  tenaculum  t;  a.v.ic,  anterior  vapinal  wall ; 
d,  denuded  surface  ;  s  s,  s  .«,,  1st  and  last  of  series  of  sutures  ;  u,  urethral  orifice  ;  c/.  clitoris.  B., 
As  seen  in  section,  l/l,  bladder  mucous  membrane  ;  a.v.w.,  anterior  vajrinal  wall ;  /,  fistulous  open- 
ing; s  «,,  suture  passed  but  not  tied.  The  shaded  areas  denote  amount  of  tissue  removed  in  denu- 
dation process. 

fistulous  openings,  so  that  the  mucous  membrane  of  the  bladder  and 
vagina  are  separated  all  round ;  the  flaps  are  brought  together  separately 


776  SYSTEM  OF  GYNECOLOGY 

by  fine  silk.  Xo  tissue  is  hereby  lost,  but  the  same  accuracy  of  suturing 
is  not  possible  as  by  the  paring  process. 

(y)  Passing  and  securing  the  sutures. — The  needleisfirst  double  threaded 
with  carbolic  silk;  a  tenaculum  seizes  the  most  inaccessible  point  of  the 
denuded  surface,  and  places  the  tissue  on  the  stretch.  By  means  of  the 
holder  the  needle  point  is  entered  on  the  vaginal  surface,  about  one-third 
of  an  inch  from  the  raw  edge,  passed  obliquely  (Fig.  188)  through  the 
tissues,  and  brought  out  at  the  bladder  orifice  of  the  fistula;  great  care 
being  taken  to  avoid  the  bladder  mucous  membrane.  The  needle  is  then 
entered  again  on  the  opposite  side  of  the  bladder  opening  of  the  fistula, 
and  passed  obliquely  through,  the  tissues ;  it  emerges 
on  the  vaginal  mucous  membrane  about  one-third  inch 
from  the  raw  edge,  and  as  nearly  opposite  the  site  on 
the  other  side  as  possible.  Care  must  be  observed 
not  to  make  the  point  of  entry  of  the  needle  more 
than  half  an  inch  from  the  raw  edge,  as  the  ureter 
may  otherwise  be  included  in  the  ligature.  The  wire 
suture  about  ten  inches  long  is  now  hooked  into  the 
silk  loop  and  pulled  through. 

In  order  to  produce  counter  pressure  on  the 
tissues  against  the  needle  point,  Emmet's  blunt  hook 
is  used  as  in  the  diagram  (Fig.  189).  Care  should 
be  taken  to  include  sufficient  tissue  in  the  sutures. 
A  series  of  these  are  now  passed  in  a  similar  manner 
^     ,        ,  about  one-fifth  of  an  inch  apart.     The  two  ends  of 

Fig.  189. —  Mode  of  an-     ,  .,  .  ,      •    ,      i     j  j_i  t 

plying  counter  press-  the  Silver  Wire  are  now  twisted  together   by  means 
ure  to  the  point  of  ^f  forceps  and  a  Sims'  adiuster  or  shield  (Fig.  186) 

of  a  blunt  hook  (Em an  instrument  devised  for  accurate  adaptation  of 

"*''''^^-  the  flap  without  producing  torsion  upon  the  tissues 

(Fig.  190).  After  all  the  sutures  have  been  thus  secured,  they  may  be  cut 
short  and  the  sharp  ends  either  covered  with  sealing  wax  or  bent  over. 
Having  ascertained  that  the  denuded  edges  are  in  accurate  apposition,  by 
inspection  and  by  the  injection  of  milk  into  the  bladder,  should  the 
fistula  be  quadrilateral  in  outline  the  resulting  cicatrix  will  be  found  to 
be  Y-shaped  ;  if  oval,  a  transverse  or  longitudinal  line  will  result.  Sims' 
sigmoid  catheter  (a  self-retaining  instrument)  with  a  long  piece  of  india- 
rul)l)er  tuljing  attached  may  be  introduced,  and  the  patient  put  back  to 
bed. 

(S)  After  Treatment.  —  The  two  chief  complications  to  be  encountered 
are  haemorrhage  into  the  bladder  and  cystitis.  The  catheter  should  be 
changed  daily,  replaced  by  a  second,  and  thoroughly  cleansed  before 
being  used  again.  It  is  better  for  the  tube  to  open  into  a  deep  dish 
filled  with  a  1  in  00  carbolic  acid  lotion.  No  other  local  treatment  is 
necessary.     The  stitches  may  be  removed  about  the  tenth  day. 

Such  is  the  operation  as  carried  out  by  Sims  and  modified  by 
Emmet. 

When  the  fistula  is  close  to  the  cervix,  and  treatment  prevented  by 


PLASTIC    GYNECOLOGICAL    OPERATIONS 


777 


its  presence,  it  is  better  to  incise  the  anterior  cervical  lip  or  to  excise  a 
wedged-shaped  piece  to  allow  of  free  inspection  and  access.  The  denuda- 
tion should  then  be  freely  made  around,  and,  in  case  of  tension,  liberating 
incisions  are  advisable :  the  sutures  should  then  be  passed  as  before. 


Fig.  100.  — Method  of  fixing  ami  twistin;^  the  sutures  iSiuis'). 


In  urethro-vaginal  fistula  the  edges  are  denuded  and  sutures  passed, 
as  in  the  operation  for  prolapse  of  the  urethral  mucous  membrane 
(p.  762). 

(ii.)  Simon's  method. — This  is  carried  out  very  extensively  in  Germany, 
and  differs  in  many  essentials  from  the  preceding.  It  is  fully  detailed  in 
that  author's  paper,  published  in  1S()2.  Simon  attaches  less  importance 
than  did  Sims  to  the  preparatory  treatment.     The  semiprone  position  is 


77S  SYSTEM   OF  GYXAiCOLOGY 

replaced  by  an  exaggerated  lithotomy  position,  the  buttocks  being  raised 
by  a  cushion,  and  the  parts  exposed  by  a  handled  speculum. 

During  denudation  Simon  endeavours  to  make  the  fistula  a  deep 
funnel-shaped  aperture,  with  walls  nearly  perpendicular  (c/.  Sims' method), 
and  thinks  incision  of  the  vesical  mucous  membrane  of  no  moment. 
Should  the  fistula  be  small  his  mode  of  suture  is  somewhat  similar  to 
that  already  described ;  in  the  larger  varieties,  however,  he  introduces 
two  sets  of  stitches  —  a  deep  or  relaxing  and  a  superficial  set ;  the  former 
enter  and  emerge  at  a  considerable  distance  from  the  raw  surface,  and  pass 
either  close  to  the  bladder  lining  or  pierce  it.  The  latter  are  passed  alter- 
nately Avith  the  deeper.  Care  is  taken  to  avoid  inclusion  of  the  mucous 
membrane  of  the  bladder  between  the  flaps.  Silk  is  always  used  in  pref- 
erence to  wire,  and  the  sutures  are  placed  very  closely  together. 

As  regards  the  after  treatment  the  catheter  is  considered  unneces- 
sary, and  the  patient  is  allowed  to  pass  the  urine  herself  at  whatever 
intervals  she  likes.  Simon  is  of  opinion  that  the  urine  has  no  ill-effect 
upon  the  healing  of  the  wound,  and  that  distension  of  the  bladder  (pro- 
vided the  stitches  were  inserted  properly  and  tied  firmly)  does  not  matter. 
There  are  no  restrictions  as  to  diet.  The  sutures  are  removed  as  early 
as'  the  fourth  or  fifth  day. 

(iii.)  Bozemcm^ s,  or  the  Button-suture  method,  is  again  quite  different 
from  the  two  already  described.  The  author  is  most  careful  in  carrying 
out  the  preparatory  treatment,  concerning  which  he  claims  priority  to 
Sims.  He  commences  proceedings  by  "  kolpoecpetasis,"  or  removing 
obstructions  to  the  view  of  the  fistula  and  to  operation  upon  it.  Any 
bands  of  adhesions  are  severed,  and  gradual  dilatation  is  effected  by 
means  of  an  elastic  bag  or  glass  plug.  This  is  continued  until  the 
fistulous  opening  can  be  well  seen,  and  the  edges  are  soft  and  lax. 

The  position  in  which  he  places  the  patient  for  operation  is  a  modified 
genu-pectoral  one  ;  that  is,  she  rests  upon  the  knees  Avith  the  legs  apart, 
and  the  chest  and  head  are  supported  in  a  horizontal  direction  by  specially 
constructed  cushions.  The  operator,  therefore,  sits  facing  the  nates,  with 
the  anterior  vaginal  wall  downwards.  An  anassthetic  may  be  given  or 
not,  but  it  is  better  avoided  on  account  of  the  awkward  position  of  the 
patient.  Bozcman  prefers  to  have  little  assistance  ;  and,  to  attain  this 
object,  a  trivalve  speculum  is  inserted  to  expose  the  fistula,  which  is 
pared  in  situ ;  the  uterus  is  not  drawn  down  by  a  volsella. 

After  paring  the  edges  the  sutures  are  passed  in  the  usual  manner, 
and  the  ends  instead  of  being  tied  are  brought  through  a  perforated 
plate  which  lies  over  the  line  of  union,  and  are  then  fastened  by  means 
of  perforated  shot.  An  ordinary  catheter  is  inserted  into  the  bladder, 
and  the  after  treatment  is  as  in  Sims'  operation. 

The  special  instruments  used  in  this  method  are  depicted  in  Boze- 
man's  original  paper,  to  which  the  reader  is  referred.  The  advantages 
claimed  are,  that  the  position  of  the  patient  allows  better  access  to  the 
fistula;  that  the  perforated  plate  gives  the  margins  of  the  flap  more 
complete  rest;  and,  finally,  that  it  also  protects  the  wound  from  urinary 


PLASTIC   GYNAECOLOGICAL    OPERATIONS  779 

and  vaginal  discharges.  Although  advocated  by  many  surgeons  in 
America  it  has  not  found  much  support  in  Europe,  where  Sims'  and 
Simon's,  or  a  modification  of  the  two,  are  usually  practised.  Xeugebauer 
of  Warsaw  performs  the  operation  in  the  same  position,  and  with  a 
special  apparatus  for  exposing  the  opening,  but  omits  the  use  of  the 
perforated  plate. 

(P>.)  Ehitroplasty  Avas  first  In-ought  into  notice  by  Jobert  of  Lamballe 
in  183-4 ;  it  consists  in  raising  a  flap  from  various  situations,  such  as  the 
posterior  wall  of  the  vagina,  the  labium,  or  even  the  thigh,  and  suturing 
it  accurately  to  the  denuded  edges  of  the  fistula.  This  operation  would 
only  be  necessary  when  there  was  much  deficiency  of  tissue ;  and  it  is 
now  almost  entirely  abandoned,  in  view  of  the  results  brought  about  by 
the  preparatory  treatment  already  described. 

(C.)  Kolpoldeisis,  or  closure  of  the  vagina  below  the  fistulous  opening, 
is  resorted  to  when  direct  closure  of  the  fistula  is  found  impossible,  and 
will  be  found  described  on  page  780. 

II.  Fistulas  requiring  Special  Treatment.  —  1.  In  vesico-utero-vaginul 
or  juxta-cervical  fistulas  the  cervix  is  involved,  and  must  be  distinguished 
from  the  vesico-vaginal  variety  in  which  the  cervix  is  intact. 

They  are  subdivided  into  superficial  and  deep  according  to  the  partial 
or  complete  sloughing  of  the  anterior 
cervical  lip. 

In  the  superficial  form  much  may  /'  y^       "^\^^      ,^ 

be  obtained  by  simple  denudation  and         /    /^  *  \^ 

suture ;    the   tissues    being    extremely       /   /       ^ ___  S^^^<^^ 

tough  from  cicatrisation  the  freshening      /  /      ^''       }'"..[... -'- -'--.^\CS- 

must  be  extensive,  as  a  healthy,  broad,     /   /         — J~l - '  "'lOr^  ... </ 

and    pliable    surface    is    more    easily     \   \         — I/'    /^^~N.'    *--t'n^ 
sutured  than  a  cicatricial  and  inelastic     ■  r LXl) ■''''"^ 

Deep  juxta-cervical  fistulas  are  very     \  \  w. .'uJ^-*^ 

rarely  amenable  to  treatment  by  suture,  ^\  \      ^1 — h'^'--V ,V'''    / 

and  it  is  generally  necessary  to  bring       \  \  ■  "        / 

the    posterior    lip    of    the    cervix    in         \  \         •  / 

apposition  with  the  vaginal  edge  of  the  '\    x,,^;       ^^/ 

fistula,    and   stitch   the   two   together. 

The  OS  uteri,  therefore,  will   open  di-  '^-  c 

rectly  into  the  bladder.     This  operation  Fig.  loi.  — .luxt.vcervicai  fistula  (supcrfimi 

has  been  termed  vesico-hystero-cleisis        ^tJl ;  'i^XT^,  \  ^S.! 

by  Pozzi.  canal ;  «,  anterior  lip  ;  x  *,,  h  h,,  series  of 

o       rr     •  J      •  J'   ,    1  1  sutures  passed. 

J.  Vesico-nteri ne  fistulas  may  be 
cervical  or  corixn-eal.  In  the  cervical  form  the  anterior  portion  of  the 
cervix  should  be  dissected  off  the  posterior  or  bladder  wall  to  a  distance 
above  the  oriiice  of  the  fistula.  The  anterior  lip  is  split  up  to  the 
cervical  opening,  and  the  denuded  surface  on  the  posterior  bladder  wall 
is  then  sutured  in  a  similar  manner  to  an  anterior  colporrhaphy,  while 
the  artificial  cervical  tear  is  treated  by  trachelorrhaphy. 


78o  SVSTEM   OF  GYNAECOLOGY 

In  the  corporeal  variety  such  an  operation  is  obviously  impossible ; 
and  the  only  treatment  feasible  is  that  of  suturing  the  two  lips  of  the 
cervix  together — hystero-stomato-kleisis  ;  the  uterine  secretions  must, 
therefore,  pass  through  the  fistulous  opening  into  the  bladder. 

3.  Uretero-vaginal  Fistulas.  —  These  are  frequentl}^  complicated  by  a 
vesico-vaginal  fistula.  Landau  has  invented  and  successfully  performed 
the  following  operation  for  this  condition :  The  patient  is  placed  in  the 
dorsal  or  left  lateral  position ;  if  a  vesico-vaginal  fistula  do  not  already 
exist,  the  surgeon  makes  one  by  the  excision  of  an  oval  flap  around  the 
ureteral  opening.  A  very  fine  gum  elastic  catheter  is  then  passed  into 
the  renal  or  proximal  end  of  the  ureter,  and  into  the  urethra  through  the 
bladder.  The  genu-pectoral  position  is  now  assumed  and  the  edges  of 
the  fistula  denuded ;  a  series  of  fine  sutures  are  passed  through  the  flaps 
at  right  angles  to  the  ureter  and  tied.  The  catheter  must  remain  in  the 
ureter  and  urethra  for  at  least  eight  days.  Should  union  take  place  the 
ureteral  opening  into  the  bladder  will  necessarily  be  higher  up  than  in 
the  natural  condition.  In  event  of  failure  kolpokleisis,  or  some  similar 
operation,  is  the  only  resource  open  to  the  patient. 

4.  Uretero-uterine  Jistulas  obviously  cannot  be  treated  in  this  manner, 
and  the  only  means  of  relief  to  be  obtained  is  by  excision  of  the  corre- 
sponding kidney  or  artificial  closure  of  the  vagina  or  vulva  by  a  plastic 
operation. 

A  recent  and  valuable  paper  on  the  treatment  of  vesical  fistulas  is 
that  by  Dr.  Winternitz  of  Tubingen,  and  is  well  worthy  of  perusal. 

The  operations  so  far  described  for  repair  of  urinary  fistulas  have 
been  "  direct "  methods ;  allusion  must  now  be  made  to  the  "  indirect " 
modes  of  cure.  These  consist  in  closure  of  the  genital  canal  at  a  point 
below  the  site  of  the  fistula,  so  that  the  portion  of  the  vagina  above  this 
becomes  a  part  of  the  bladder ;  menstruation  will  then  take  place  into 
this  viscus. 

Three  varieties  have  been,  devised :  — 

1.  Antero-posterior  closure  of  the  vulva,  or  episiostenosis  (Vidal),  the 

inner  surfaces  of  the  labia  majora  being  denuded  and  brought 
together  by  sutures. 

2.  Complete  vulval  closure,  with  the  formation  of  an  artificial  recto- 

vaginal fistula. 

?>.  Obliteration  of  the  vaginal  canal  transversely  (Icolpoldeisis). 

The  two  former  have  proved  so  unsatisfactory  that  they  have  been 
practically  abandoned.  In  kolpokleisis,  however,  in  some  rare  cases,  we 
have  a  valuable  operation.  The  indications  for  its  performance  are  when 
the  loss  of  tissue  is  too  great  to  allow  of  direct  suture  of  the  fistulous 
edges;  when  there  is  much  cicatricial  tissue  at  the  margins  of  the  fistula, 
or  when  they  are  adherent  to  subjacent  bone;  lastly,  Avhen  there  is  risk 
of  wounding  the  peritoneum. 

Kolpokleisis,  or  transverse  obliteration  of  the  vagina,  may  be  performed 
in  three  places  according  to  the  situation  of  the  fistula,  at  the  urethral 
portion,  that  over  the  ])ase  of  the  bladder,  and  the  fornix. 


PLASTIC   GYNECOLOGICAL    OPERATIONS 


781 


For  the  first  of  these  Simon's  position  is  the  best,  but  for  the  two 
latter  the  decubitus  advocated  by  Neugebauer  is  to  be  preferred. 

A  ring  is  first  marked  out  by  the  point  of  a  knife  on  the  vaginal 
mucous  membrane,  below  the  fistulous  opening;  sufficient  room  being 
allowed  to  avoid  the  cicatricial  tissue  always  present.  Denudation  is 
performed  on  the  anterior  surface  with  a  sound  in  the  bladder  as  a  guide, 
while  the  finger  in  the  rectum  is  necessary  during  the  paring  of  the 
posterior  surface. 


r.  V-  w.— 


Fio.  192.  —  Kolpoklcisis.  Surfaces  denuded,  and  one  suture  passed,  v.v.w.,  vesico-vaginal  wall  abovf 
fistulous  opening/;  v  ?),,  v.agina;  r.v.w.,  recto-vag-inal  wall ;  c,  os  uteri  externum  ;  «,  urethra  ;  ;^ 
perineum  ;  ?■,  rectum. 

The  sutures  of  wire  or  carbolic  silk  are  passed  by  means  of  two  short 
half-curved  stout  needles,  one  at  each  end ;  both  are  passed  from  above 
downwards.  The  anterior  needle  (Fig.  102)  will  be  entered  on  the  vaginal 
surface,  below  the  fistula,  then  pass  through  the  substance  of  the  vesico- 
vaginal septum,  beneath  the  denuded  area,  and  out  again  on  the  vaginal 
mucous  membrane ;  the  posterior  needle  will  enter  the  recto-vaginal  wall, 
immediately  above  the  edge  of  the  denuded  area,  pass  beneath  this,  and 
have  its  exit  on  the  vaginal  aspect  opposite  to  that  of  the  anterior  needle. 
Several  similar  sutures  are  passed,  and  they  are  then  tied.  Great  care 
should  be  taken  to  avoid  injuring  the  bladder  or  rectal  mucous  membrane 
by  including  either  in  the  loop  of  the  suture. 

The  objection  to  this  method  is  that  the  vagina  being  closed,  sexual 
connection  is  impossible;  the  patient  should  be  warned  of  this  result 
before  consent  to  the  operation  is  obtained. 


782  SYSTEM   OF  GYNMCOLOGY 


Feecal  fistulas  may  be  recto-vaginal,  entero-vaginal,  or  recto-labial. 
Recto-ragiital  listula  is  an  opening  between  vagina  and  rectum,  and  may 
be  the  result  of  parturition,  when  the  lower  portion  of  the  sutured  peri- 
neum has  h-ealed  after  suture,  but  the  upper  still  remains  open.  Advan- 
cing malignant  disease,  rupture  from  abscess,  and  various  kinds  of  ulcera- 
tive processes,  may  also  lead  to  this  condition.  In  cases  in  which  a  plastic 
operation  is  advisable,  should  the  opening  be  low  down,  it  is  better  to 
cut  through  the  perineum  and  re-suture  the  two  flaps  after  the  mannei- 
already  described  in  complete  perineal  rupture  (p.  747)  :  if  the  orifice 
be  higher  up  denudation  should  be  carried  out  over  an  area  around  it,  and 
earbolised  silk  sutures  passed  as  in  vesico-vaginal  fistulas. 

JoHX  Phillips. 

REFERENCES 

1.  BozEMAX.  Remarks  on  Vesico-vaginal  Fistula,  1856. — 2.  Duke,  Alexander. 
Dublin  Medical.  Pi-ess,  May  »th,  1888.— 3.  Duhrssen.  Archiv  fiir  Gyniikol.  18<)4, 
Bel.  xlvii.  S.  281.  —  4.  Emmet.  The  Principles  and  Practice  of  Gynsecology,  1885,  p. 
817. — 5.  Fritsch.  "  Ueber  plastisclie  Operationen  in  der  Scheide,"  Centralblutt  fiir 
Gijniik'jlogie,  1885,  No.  49,  S.  804. — (>.  He^ar.  Die  operative  Gi/niikolor/ie,  1881,  S. 
4()2.  — 7.  Landau.  "Ueber  Eiistehung,  etc.  der  Hariileiterseheideiitisteln,"  Arcliiv 
fiir  Gyniikologie,  1870,  Bd.  ix.  S.  42().  —  8.  Lefort,  Lkon.  "  New  Method  for  Curiii"; 
'Prolap.se  of  the  Uterus,"  Bull,  de  Therapeut.  Apr.  30,  1877.-0.  Marckwald.  "  Ueber 
die  Ke.irelmantel-fijrraige  Excision  der  Vaginal  Portion,"  etc.,  Archiv  fiir  Gyniikologie, 
Bd.  viii.  S.  48.  —  10.  Neugebatjer.  "  Casuistik  von  140  Vesico-Uterinfisteln,"  Archiv 
fdr  Gyniik.  Bd.  xxxiii.  S.  270,  and  Bd.  xxxiv.  S.  145. — 11.  ShuckinCx.  Centralblatt 
f.  Gyn.  1888,  Bd.  xii.  S.  ()82.  — 12.  Simon.  Uebn'  die  Heilunq  der  Blasenscheiden- 
Jisteln,  Rostock.  — 13.  Vidal.  "  Obliteration  of  the  Orifice  of  the  Vagina  as  a  Treat- 
ment for  Vesico-vaginal  Fistula,"  Aim.  de  la  chir.  franc,  et  etrangere,  1814,  p.  208. 
— 14.  Webb,  R.  Curtis.  "On  Mackenrodt's  Operation,"  Thesis  for  M.B.  degree, 
Cambridge,  189fi.  — 15.  Winternitz.  Centralblatt  fiir  Gyniikologie,  1895,  No.  15,  S. 
377,  with  Bibliography. 

J.   P. 


DISEASES   OF  THE   FALLOPIAN   TUBES 

Injuries  of  the  Fallopian  Tubes.  —  The  Fallopian  tubes  are  tough,  and 
no  structures  in  the  body  are  better  protected  by  their  position  and 
relations.  They  accontmodate  themselves,  as  is  well  known,  to  the 
normal  changes  of  the  uterus  in  pi-egiiancy.  A  wound  of  a  Fallopian 
tube  from  a  dagger  oi-  similar  weajjon  would  involve,  in  all  prol)ability, 
more  serious  injuries  to  neighbouring  vessels  and  viscera  than  to  the  tube 
itself. 

A  healthy  tube  is  sometimes  cut  through  during  an  abdominal  section. 
I  have  noticed  that  it  does  not  bleed  very  freely  ;  the  blood  mostly  issues 
from  small  vessels  in  tlie  investing  mesosalpinx.  The  serious  feature  of 
such  an  injury  is  the  exposure  of  a  mucous  canal  which  may  contain 
septic  matter.     In  most  cases  there  is  little  or  no  danger  even  from 


DISEASES   OF  THE  FALLOPIAN   TUBES  783 

this  source  ;  still  it  is  best  to  touch  the  exposed  mucosa  with  tincture  of 
iodine,  especially  if  the  surgeon  intends  to  carry  out  some  other  part  of 
the  operation  before  removing  the  wounded  tube.  It  is  seldom  of  any 
use  to  sew  up  the  injured  tube,  as  it  usually  has  to  be  removed  with 
adjacent  diseased  structures. 

The  experience  of  countless  ovariotomies  teaches  us  that  the  healthy 
tube  bears  well  the  necessary  injury  inflicted  by  the  ligature  of  the 
pedicle.  The  stump  seldom  sloughs,  and  when  gangrene  does  occur  the 
remains  of  the  tube  are  not  necessarily  the  seat  or  the  origin  of  this 
grave  incident.  In  cases  of  extensive  disease  of  the  appendages,  on  the 
other  hand,  the  unhealthy  tissues  of  the  tube  do  not  always  tolerate  the 
ligature.  Sometimes  the  silk,  when  tightened,  cuts  through  the  tube. 
The  real  danger  in  such  a  case  is  not  haemorrhage,  but  exposure  of  the 
mucosa,  as  explained  above ;  suppuration  around  the  ligatured  stump  is 
not  unknown.' 

Atrophy  and  Hypertrophy  of  the  Tube.  —  After  the  menopause  the 
tube  shares  in  the  atrophic  process  which  involves  the  uterus.  It  like- 
wise undergoes  a  certain  amount  of  involution  after  pregnancy.  The 
term  atrophy  cannot  be  applied  to  the  arrested  development  of  a  mal- 
formation. In  subjects  who  have  died  from  chronic  wasting  diseases  the 
tube  is  often  found  like  a  piece  of  thin  twine,  the  fimbriae  being  reduced 
to  small,  very  pale,  red  shreds.  In  twisting  of  an  ovarian  pedicle  atrophy 
of  the  tube  may  proceed  to  such  an  extent  as  to  reduce  it  to  a  thin  cord. 
In  extreme  cases  the  entire  pedicle  may  part  in  the  middle,  and  the  uterine 
as  well  as  the  distal  end  of  the  divided  tube  is  then  always  found  in  a 
state  of  extreme  atrophy.  The  dragging  of  an  omental  adhesion  may 
cause  stretchiiig  and  atrophy  of  the  tube.  As  a  rule  adherent  omentum 
is  dragged  down ;  but  in  exceptional  cases  the  omentum  may  pull  up 
the  tube  and  stretch  it  considerably.  I  have  observed  two  cases  where 
this  condition  was  well  marked,  the  tube  being  atrophied. 

Perimetritic  bands  pressing  on  the  tube  may  bring  on  local  atrophy, 
with  obstruction  of  the  lumen.  Extreme  atrophy  of  the  tube  may  be 
occasioned  by  pressure  between  the  pelvic  wall  and  a  large  fibroid  of 
the  uterus. 

Hypertrophy  of  the  tube  is  a  physiological  condition  in  pregnancy. 
It  must  be  remembered  that  in  a  healthy  young  woman  the  tube  is  a 
stout,  deep  red,  tortuous,  worm-like  structure,  with  thick  budding  fimbriae 
almost  as  big  as  the  petals  of  a  small  carnation.  Inexperienced  operators, 
whose  notions  of  a  '•'■  normal "  tube  are  based  on  the  examination  of 
dissecting-room  subjects,  or  specimens  shrunken  from  the  action  of  spirit, 
may  regard  a  healthy  tube  as  diseased,  or  at  least  hypertrophied.  True 
hypertrophy  of  the  tube  occurs  Avhen  a  myoma  develops  in  the  uterus 
near  the  cornu,  and  in  all  cases  of  large  "fibroids"  where  the  tumour 
does  not  press  the  tube  against  the  pelvic  wall.  In  ovarian  cystic  disease 
and  in  other  pedunculated  pelvic  tumours  the  tube  certainly  grows 
longer,  but  it  is  not  the  essential  tissues  that  undergo  hypertrophy.  I 
have  always  found  that  the  mucosa  appears  more  or  less  atrophied,  the 


784 


SYSTEM  OF  GYN.-ECOLOGY 


fimbrise  being  often  much  reduced  in  size.  A  yet  more  extreme  condi- 
tion is  seen  in  the  simple  broad  ligament  cyst  and  other  non-peduncu- 
lated  tumours  of  the  pelvis,  where  the  tube  undergoes  great  stretching 
and  a  certain  amount  of  hypertrophy,  in  which  the  mucosa  assuredly 
takes  no  part. 

Hypertrophy  of  the  muscular  coat  occurs  in  some  forms  of  salpingitis. 

Inflammation  of  the  Tube  or  Salpingitis.  —  The  earlier  essential  and 
purely  local  changes  which  occur  when  the  tube  is  inflamed  Avill  be  con- 
sidered in  the  following  paragraphs.  These  changes  affect  the  coats  of 
the  tube  and  the  ostium.  The  remarkable  complications  which  follow 
when  the  disease  is  well  established  will  be  fully  discussed  in  the  section 


Fio.  193.  —Section  of  a  healthy  tube  from  a  younff  subject.  The  correspondinpr  ovary  was  removed,  as 
it  showed  sig-ns  of  incipient  cystic  disuaae.  The  opposite  ovary  formed  a  lar^o  tumour.  The  plicae 
are  delicate  and  well  formed  ;  very  larj^c  vessels  run  in  the  muscular  coat.     (Beck,  5  inch.) 

on  pelvic  inflammation.  Here  I  need  only  note  that  amongst  these 
changes  are  hydrosalpinx,  pyosalpinx,  and  the  rarer  forms  of  haimato- 
salpinx.  The  union  of  the  cavity  of  a  tube  which  has  become  cystic 
with  the  cavity  of  a  cyst  of  any  kind  in  the  adjacent  ovary  produces  the 
commoner  form  of  tubo-ovarian  cyst,  which  is  to  be  distinguished  from 
the  tei-atological  condition  to  which  Mr.  Bland  Sutton  has  given  the 
name  of  "ovarian  hydrocele."  The  development  of  the  first  or  inflam- 
matory variety  was  dosci'ibed  by  myself  in-  1887  {\T^})).  Button  makes 
the  same  distinction,  or  rather  goes  fai-tlier,  and  denies  that  an  ovarian 
hydrocele  is  a  "tubo-ovarian  cyst"  at  all. 

In  the  paragraphs  on  new  growths  of  tlic  tube,  however,  I  shall  return 
to  the  subject  of  salpingitis,  bringing  forward  evidence  that  these  new 


DISEASES    OF   THE   FALLOPIAN   TUBES 


785 


growths  specially  affect  tubes  Avliich  have  long  been  subject  to  inflamma- 
tion. Indeed,  it  will  be  shown  that  papilloma,  itself  prone  to  undergo 
malignant  degeneration,  seems  to  originate  amongst  inflammatory  prod- 
ucts. • 

The  observer,  when  studying  sections  of  diseased  Pallopian  tube,  must 
avoid  the  common  error  of  taking  normal  for  morbid  appearances.  Xor 
must  he  conclude  that  the  presence  of  normal  amongst  morbid  tissues 
necessarily  implies  that  the  disease  is  not  advanced.  The  columnar 
epithelium  lining  the  plicae  in  health  is,  of  course,  perfect ;  but  it  is  by 
no  means  the  first  structure  to  be  distinctly  affected  by  the  inflammatory 


Ftg.  194.  - 


-  One  of  the  plicoe  in  Fig.  193,  as  seen  under  a  J  inch  ob.iective.     It  is  slender  and  well  formed  ; 
its  surface  is  invested  with  columnar  cUiated  epithelium. 


process.  In  health  large  vessels  with  stout  coats  are  to  be  found  in  the 
plicae  and  at  their  roots.  These  vessels  undergo  changes,  in  relation  to 
the  menstrual  cycle  and  pregnancy,  not  yet  perfectly  determined.  In 
inflammation  they  tend,  I  find,  to  become  obstructed  rather  than  en- 
larged. The  pathologist  must  not  forget  that  in  tubes  removed  by 
operation  an 3^  marked  change  in  the  blood-vessels  may  be  due  to  the 
ligature. 

The  naked-eye  appearances  in  the  earlier  stages  of  salpingitis  are 
not  very  distinct,  even  when  the  microscope  can  already  reveal  marked 
changes.  A  highly  vascular  appearance  of  the  tube  may  be  due  to 
menstruation  or  the  ligature,  and  a  considerable  amount  of  mucus 
may  be  seen  in  the  healthy  tubes.  Exuberant  fimbriiv  are  evidence 
of  health  and  vigour,  not  of  disease ;  the  fimbria^  in  inflammation  tend 
to  shorten  and  retract,  as  will  be  explained  further  on. 

3e  * 


786  SVSTjEJ/  of  GYN^-ECOLOGY 

In  early  salpingitis  tlie  most  prominent  feature  is  small-celled  infiltra- 
tion of  the  plicae,  Avhich  causes  them  to  become  thick  and  club-shaped. 
(Compare  Figs.  193  and  194  with  Figs.  195  and  196.)^ 

The  blood-vessels,  at  first  perhaps  dilated,  soon  appear  narrower  than 
in  health.  There  is  no  rapid  desquamation  of  the  epithelium ;  indeed, 
this  change  need  not  take  place  at  all.  Mucoid  degeneration  of  the  cells 
is  not  rare ;  Weichselbaum  admits  its  existence.  It  will  be  shown,  how- 
ever, that  in  advanced  salpingitis  the  epithelium  persists  in  certain  places. 
Even  when  the  inflamed  tube  becomes  obstructed  and  dilated  for  months 
or  years  the  epithelium  may  remain  intact.     In  that  case,  as  in  less 


Fio.  195.  —  Section,  near  the  ostium,  of  an  inflamed  tube.    The  plicae,  normally  very  slender  in  this  part 
of  the  tube,  are  thickened  by  small-celled  infiltration  (J  inch  objective). 

chronic  disease,  the  cells  become  low  and  cubical,  and  lose  their  cilia  (Fig. 
197).  The  nuclei  become  large  and  spheroidal,  nearly  filling  the  cell. 
Schramm  describes  this  appearance  as  occurring  early  in  tubercular  dis- 
ease of  the  tube. 

A  characteristic  change,  peculiar  for  evident  reasons  to  salpingitis, 
soon  follows.  This  change  is  the  adhesion  of  the  edges  of  adjacent 
fimbriae.  The  small-celled  infiltration  presses  the  swollen  edges  together, 
and  the  epithelial  surfaces  thus  in  contact  become  destroyed,  so  that  the 
cells  disappear  by  a  purely  secondary  change  quite  unlike  what  is  under- 
stood by  catarrhal  desquamation.  The  plicae,  however,  remain  a])art 
near  their  roots.     If  ere  the  epithelium  remains  intact,  another  proof  how 

'  Tlif;  photo-micrograplis  illnst.nUin^  RalpiiiKitis  woro  kindly  taken  by  Mr.  Edmund 
K')ii<;litfin  and  Mr.  H.  Coseiis  from  sections  of  diseased  tubes  which  I  have  removed  by 
operation.     I  have  been  careful  to  select  cases  whore  the  clinical  history  was  very  clear. 


DISEASES    OF   THE   FALLOPIAN   TUBES 


787 


Fig.  196.  —  Section  of  a  plica  (same  case  as  Fi^;  195),  shomns  the  earlier  chan<?es  seen  in  salpingitis.  It 
may  be  compared  with  the  healthy  plica,  Fig.  194.  Sraall-celletl  infiltration  has  taken  place,  caus- 
ing distinct  thickening,  especially  towards  the  free  edge.  Tlie  epithelium  is  intact.  (\  inch 
objective.)  From  a  woman  aged  33,  subject  to  pelvic  inllamniation  for  about  seven  years.  The 
appendages  were  removed  and  advanced  disease  discovered.  The  portion  here  seen  displays  the 
efl'ect  of  a  recent  attack  of  inflammation  over  an  area  which  had  previously  escaped  disease. 


Fto.  197. —  Section  showing  the  free  surface  of  the  interior  of  a  tul)e  which  h.ad  been  obstructed  and 
dilated  for  a  long  period.  From  a  woman  aged  42,  who  had  sutfcred  for  over  ten  years  from  chronic 
l)elvic  inllamniation.  The  epilholium  has  not  disappeared,  but  the  colls  have  become  cubical  and 
have  lost  their  cilia.  The  middle  coat  is  reduced  to  fibrous  tissue  ;  the  vessels  and  muscular  fibre;* 
have  entirely  disappeared.     (J  inch  objective.) 


788 


SYSTEM   OF  GYNECOLOGY 


little  it  is  subject  to  primary  cliange  in  salpingitis.  In  consequence  of 
the  adhesion  of  the  plicee  along  their  edges  spaces,  often  lined  with  per- 
fect epithelium,  appear  in  sections.  There  can  be  no  doubt  about  the 
fusion  of  plicte ;  many  independent  observers  have  noted  it :  this  being 
the  case  there  is  no  mystery  about  the  spaces  lined  with  epithelium ; 
they  are  in  no  sense  cysts  at  first,  but  they  often  become  so  after  a  time, 
when  a  long  and  broad  area  of  plicae  sinks  embedded  in  inflammatory 
effusion.  The  observer  must  not  confound  this  pathological  union  of 
plicae  with  the  nornuil  union  of  the  tips  of  plicae  sometimes  seen  in 


Fig.  198.  — Section  of  an  inflamed  tube,  in  its  middle  third,  showing  active  inflammation,  more  advanced 
than  in  Fip.  19fi.  The  small-celled  infiltration  is  marked,  the  free  edges  of  the  plicas  are  much 
swollen.     To  the  left  they  are  becoming  fused  and  their  eiathelium  is  disiii)i)earing. 

healthy  tubes.  Nor  must  the  cut-off  spaces  be  taken  for  the  teratological 
diverticula  (Whitridge  Williams),  not  rare  in  tubes  otherwise  normal. 
These  diverticula  contain  healthy  plicae. 

In  the  middle  coat  cedema,  separating  the  muscular  fibres,  is  very 
frequent;  and  the  small-celled  infiltration  is  constant.  The  oedema  is 
the  chief  factor  in  obstructing  the  ostium  from  within,  —  the  "  salpingitic 
closure  of  the  ostium,"  —  of  which  more  will  be  said  presently.  The 
inflammatory  infiltration  may  end  by  organising  so  as  to  form  fibrous 
tissue  which  makes  the  tube  feel  tough.  The  "kinking  "  of  the  tube, 
so  often  described,  is  usually  a  congenital  condition,  not  rarely  due  to 
shortness  of  the  mesosalpinx.  It  is  always  increased  by  this  sclerosis 
of  the  middle  coats,  and  by  perimetritic  changes  without.  As  the  outer 
or  serous  coat  of  the  tube  is  part  of  the  peritoneum,  its  changes  in  in- 
flammation are  those  seen  in  peritonitis. 


DISEASES   OF  THE  FALLOPIAN   TUBES  789 

The  more  advanced  form  of  uncoiii  plicated  inflammation  of  tlie 
tube  should  be  called  purulent  salpingitis.  Pyosalpinx  implies  also 
closure  of  the  tube :  in  purulent  salpingitis  the  ostium  is  usually,  but 
not  always  closed.  I  have  seen  pus  issuing  from  the  open  ostium  of 
a  tube  not  greatly  enlarged ;  this  was  the  case  in  the  specimen  from 
which  Fig.  198  was  prepared.  Hartmann  and  other  observers  describe 
the  same  appearance. 

Under  the  microscope  the  plicae  are  found  thickened  by  infiltration 
of  round  cells  (Fig.  199),  and  reduced  in  length.     The  epithelium  on 


Fig.  199.  — The  free  surface  of  the  interior  of  a  suppurating  tube.  The  plice  are  extremely  thickened, 
but  not  all  fused  together.  The  deeper  parts  were  less  vascular  than  in  health  ;  the  muscular  coat 
was  hypertrophied.  From  a  woman  ajred  44,  subject  to  symptoms  of  pelvic  inflammation  for  four 
years  :  very  severe  for  four  months  before  operation.     Double  pyosalpinx  was  discovered. 

the  surface  is  always  lost,  to  a  great  extent,  but  deeper  down  are  spaces 
in  which  it  usually  persists  (Fig.  200).  In  short,  we  see  an  advanced 
stage  of  the  changes  already  described.  In  part,  however,  as  in  Fig. 
200,  there  is  evidence  of  actual  breaking  down  of  the  diseased  plicae, 
granulation  tissue  appearing  on  the  free  surface.  When  ])vosalpinx 
exists  the  diseased  mucous  surface  is  ultimately  opened  out  by  the- 
stretching  of  the  walls  of  the  obstructed  tube ;  thus  it  suffers  further 
damage,  and  may  be  entirely  reduced  to  a  surface  of  granulation  tissue 
—  to  an  abscess  wall,  in  fact.  Yet  experience  shows  that  even  in  long- 
standing pyosalpinx  the  epithelium  is  not  always  destroyed. 

The  ])lica^  in  purulent  salpingitis,  reduced  to  low  tuberous  elevations 
(Fig.  19S).  are  far  less  vascular  than  in  health;  though  a  few  abnor- 
mally thick-walled  vessels  remain.  INIany  vessels  disappear,  doubtless 
through  i)ressure  of  inflammatory  products. 


790 


SYSTEM   OF  GYNECOLOGY 


The  middle  coat  is  ahva3'S  more  or  less  infiltrated  witli  small  cells 
in  purulent  salpingitis.  Sometimes  there  is  actual  hypertrophy  of  the 
muscular  fibres  ;  more  often  an  increase  of  connective  tissue  is  observed. 
In  consequence  the  middle  of  an  affected  tube,  -with  its  low  plicte  and 
thick  walls,  often  looks  like  the  uterine  end  of  a  healthy  tube  (Fig.  198). 

A  general  atrophy  of  the  affected  structures  in  the  tube  may  and  often 
does  follow  long-standing  inflammation  (Fig.  197).  More  frequently 
the  long-diseased  tube  shows  several  stages  of  inflammatory  change 
simultaneously.  A  tract  of  granulation  tissue  may  be  bounded  on  one  side 
by  dense  cicatricial  fibres,  showing  atrophy  of  the  structures  involved ;  in 


FtG.  200.  — Section  of  a  suppurating  tube,  .showing  ndvancofl  disease.  Fusion  of  the  plicaj  is  complete, 
and  mucli  granulation  tissue  lies  on  the  free  surface  of  the  mucosa.  The  cysts,  or  pseudo-cysts, 
representing  the  spaces  between  the  roots  of  the  jilice,  have  not  lost  all  their  ei)ithelium.  From  a 
woman  aged  20,  subject  for  three  years  to  pelvic  intlainmation.  Seven  months  before  the  append- 
ages were  removed  the  curette  was  applied  to  the  uterine  cavity.  The  patient  disregarded  advice, 
pot  up  too  soon,  and  an  acute  attack  occurred  with  high  temperature.      IJoth  ftibcs  were  found 

full  of  I)US. 

another  direction  it  may  impinge  on  plicae  which  seem  almost  healthy, 
resolution  having  evidently  taken  place.  I  find  that  tliesc  irregular 
•appearances  are  the  rule.  Spaces  actually  cystic  are  usually  observed 
in  advanced  salpingitis.  Sometimes  they  seem  to  be  of  lymphatic  origin. 
The  presence,  however,  or  rather  the  persistence  of  epithelium  in  many 
of  these  cysts  proves  their  true  nature,  which  has  already  been  ex])lained. 
It  is  easy  to  understand  why  these  changes  proceed  irregularly  ;  for 
in  the  clinical  history  of  any  chronic  case  we  know  that  exacerbations  are 
common,  and  tliat  enforced  rest  ensures  a  certain  or  uncertain  degree  of 
amelioration.  Subsequent  negle(;t  makes  matters  worse,  and  the  disease 
once  more  advances.     When  a  j)yosali)iiix  is  established  the  pus  may 


DISEASES    OF   THE   FALL0PL4N   TUBES  791 

not  press  on  the  tubal  walls  with  any  degree  of  steadiness ;  indeed,  it 
may  occasionally  escape  into  the  uterus,  so  that  for  a  time  the  condition 
which  constitutes  pyosalpinx  ceases  to  exist.  In  other  cases  the  pressure 
may  be  steady,  but  the  pus  degenerates  into  a  watery  fluid,  and  the  mucosa 
and  muscular  coat  into  more  or  less  pure  fibrous  tissue. 

In  consequence  of  the  irregular  course  of  the  inflammatory  process 
the  appearances  in  diseased  tubes  are  very  puzzling.  Hence  intricate 
forms  of  classification  have  been  devised,  not  always  on  truly  scientific 
principles.  The  dilated  cystic  cavities  sometimes  convert  the  tube  into  a 
strange-looking  structure  ;  and  when  the  tube  is  extremely  contorted,  it 
may  appear  on  section  to  have  more  than  one  lumen.  Tracts  of  hyper- 
trophied  muscular  tissue  sometimes  present  an  unusual  appearance,  but 
the  muscle  cells  may  here  represent  a  new  growth  rather  than  an  inflam- 
matory product.  I  shall  refer  to  this  subject  in  my  observations  on 
myoma  of  the  tube. 

Changes  in  the  Ostium. — The  abdominal  end  of  the  tube  is  not 
necessarily  obstructed  even  in  chronic  salpingitis.  I  have  seen  an  open 
ostium  in  advanced  suppurative  inflammation,  which  is  one  reason  why 
that  term  must  not  be  used  as  identical  with  "pyosalpinx."  In  these 
cases  the  general  peritoneal  cavity  is  protected  from  the  pus  by  peri- 
metritic bands  near  the  ostium  which,  though  actually  open,  can  only 
pour  its  contents  into  a  narrowly  limited  space. 

As  a  rule,  however,  the  ostium  in  salpingitis  becomes  more  or  less 
obstructed  and  more  or  less  permanently  closed.  The  obstruction  may 
arise  from  without  or  from  Avithin  the  tube. 

To  obstruction  from  without  I  have  ap^Dlied  the  term  "  perimetritic 
closure  of  the  ostium."  In  this  condition  the  outer  coat,  which  is  part 
of  the  peritoneum,  is  affected.  The  adjacent  peritoneum  may  be  inflamed 
before  the  tubal  mucosa  is  involved.  A  little  deposit  covering  the  delicate 
fimbrice  as  they  lie  on  the  surface  of  the  outer  aspect  of  the  ovary  is 
sufficient  to  bind  them  down,  and  when  the  deposit  is  organised  the  ostium 
becomes  firml}^  closed.  In  ascites,  and  esj^ecially  in  ruptured  ovarian 
cyst,  I  have  seen  the  fimbriae  assume  the  form  of  chalk-like  wattles. 
This  is  probably  a  result  of  inflammation  and  of  simultaneous  deposit  of 
salts  from  the  morbid  fluid.  Diseased  fimbriae  are  eminently  adapted 
to  receive  fibrous  deposit  (15^/).  Sometimes,  on  scraping  away  bands  of 
lymjih  in  the  course  of  an  operation,  the  fimbrice  come  in  sight,  well 
formed  and  bright  red,  being  full  of  blood.  In  such  cases  little  or  no 
salpingitis  may  be  present.  As  a  rule,  however,  when  its  ostium  is 
closed  from  without  in  this  manner  the  tube  is  actually  the  seat  of 
inflammation;  and  the  perimetritis  which  causes  the  closure  is  the 
result  of  extension  of  inflammatory  processes  from  the  tubal  canal. 
This  extension  protects  the  peritoneal  cavity  even  more  completely 
when  the  ostium  is  directly  closed  than  when  it  remains  patulous, 
yet  cut  off  from  the  great  serous  cavity  in  the  manner  explained 
above. 

The  accompanying  sketch  (Fig.  201)  represents  a  characteristic  exam- 


r92 


SYSTEM   OF  GYX.-ECOLOGY 


pie  of  purely  perimetritic  closure  of  the  ostium.  The  well-formed  and 
exuberant  fimbria?  were  packed  in  a  deep  pouch,  on  the  outer  side  of 
the  ovary,  formed  by  a  firm  band  of  membrane.     In  the  drawing  the 

fimbria?  are  displayed  as  they  appeared 
when  pulled  half  out  of  the  pouch.  The 
ostium,  before  the  parts  were  disturbed, 
lay  deep  in  the  pouch,  completely 
obstructed.  The  tube  was  tortuous, 
being  kinked  by  some  firm  perimetritic 
bauds ;  it  was  also  the  seat  of  salpin- 
gitis, but  the  ostium  was  not  closed  by 
changes  in  the  mucosa. 

To  obstruction  from  within  I  have 
applied  the  term  "  salpingitic  closure  of 
the  ostium."     By  causing  the  accumu- 

Fio.  201.  — Ovary  and  tube  showing  obstruc-   latiou    of   mUCUS   Or  pUS  Avithiu,   it  is   tllC 

tion  of  the  ostium  by  a  penmetritic  niost  important  agent  in  the  establish- 

band  which  forms  a  deep  pouch.     The  ,        r    t       i  i     ■  i  i     • 

fimbria  have  been  partly  pulled  out  of  mcut  01  hydrosalpinx  and  pyosalpiux. 
the  pouch.   A  bristle  passes  into  the  j^  occurs  in  a  large  proportion   of  the 

pouch  out  of  the  ostmm.  .        .    .°       ^       >- 

cases  of  salpingitis.  The  mucous  mem- 
brane and  the  middle  coat  become  greatly  thickened  by  inflammatory 
processes  already  described;  they  swell  and  bulge  round  the  ostium, 
and  ultimately  close  over  it.  The  fimbriae  do  not  retract  like  the 
tentacles  of  a  sea-anemone ;  the  infiltrated  tissues  simply  close  over 
them,  till  they  lie  reduced  to  plica? 
inside  the  tubal  canal.  A  glance  at 
Fig.  202  will  show  the  difference  of  this 
form  of  obstruction  from  that  already 
described.  Around  the  bristle  the 
thickened  tubal  walls  bulge  high,  the 
aidematous  ovarian  fimbria  alone  re- 
mains outside.  The  perimetritic  bands 
behind  and  above  the  bristle  must  not 
be  mistaken  for  fimbricB.  When  the 
bulging  structures  touch  and  adhere 
over  the  side  of  the  ostium  the  obstruc- 
tion becomes  very  firm. 

Owing  to  the  anatomical  characters  Fig 
of  the  part,  stricture  of  the  uterine 
end  of  the  tube,  after  the  manner  in 
which  the  ostium  is  so  often  closed, 
is  impossible.  A  firm  perimetritic  band  may  press  on  the  outside  of 
the  tube  near  the  uterus;  more  frequently  the  uterine  end  is  closed  in 
salpingitis  simply  by  the  swelling  of  the  mucous  membrane. 

The  natural  tendency  of  an  obstructed  tnV)e  is  doubtless  towards  cure 
V)y  spontaneous  rtdicf  of  the  obstruction.  The  lial)ility  of  the  j)atient  to 
repeated  atta(-ks  of  pelvic  iiiflaiuination  often  [ircvents  spontaneous  cure. 


202. — Tube  Rhowinp  obsti  notion  of  the 
ostium  froiri  inllaimnatory  swollinsr  of  its 
coats.  The  end  of  the  tube  has  been  drawn 
up  from  the  ovary  and  the  ostium  forcibly 
oiioned  ;  a  bristle  lies  in  its  orifice. 


DISEASES   OF   THE   FALLOPIAN    TUBES  793 

Very  extensive  changes  follow  chronic  obstruction,  some  of  which  are 
described  in  the  chapter  on  pelvic  inflammation.  Others,  more  severe, 
I  will  dwell  on  presently,  and  show  how  an  inflamed  tubal  mucosa  may 
become  papillomatous  ;  and  how  the  new  growths  may  undergo  cancerous 
degeneration. 

Closure  of  the  uterine  end  by  simple  swelling  of  the  mucous  mem- 
brane must  obviously  be  relieved  when  the  swelling  subsides ;  it  is 
not  apt  to  be  so  permanent  as  salpingitic  or  perimetritic  closure  of  the 
ostium.  Temporary  subsidence  of  the  swelling  of  the  mucosa  at  the 
uterine  end  fully  accounts  for  "  hydrops  tubte  profluens."  The  ostium 
remains  in  these  cases  flrmly  closed,  but  the  fluid  in  the  tube  rushes  out 
of  the  nterine  end  and  escapes  externally. 

This  condition,  termed  "  hydrops  profluens,"  may  be  caused  bj^  simple 
liydrosalpinx,  by  congenital  tubo-ovarian  cyst  ("Ovarian  hydrocele"  of 
Bland  Sutton),  or  by  growths  within  the  tube,  as  in  No.  5  in  the 
papilloma  series,  and  No.  15  and  No.  17  in  the  cancer  series.  Great 
(luantities  of  fluid  may  escape.  The  term  ''  hydrops  tubae  profluens  " 
indicates  rather  a  symptom  than  a  definite  disease.  The  symptom,  as 
the  above  ol)servati()ns  indicate,  may  be  of  grave  import. 

Tuberculosis  of  the  Tube.  —  This  interesting  disease  has  attracted 
much  attention  since  chronic  affections  of  the  appendages  have  been 
studied  in  a  scientific  manner.  For  precise  information  on  its  essential 
nature  we  must  rely  upon  the  bacteriologist  and  authorities  on  tuber- 
culosis. The  affected  tissues  undergo  changes  which  deserve  some 
consideration  in  these  pages.  The  proportional  frequency  of  tubercle 
of  the  tube  has  not  been  accurately  determined.  The  statistics  of  sev- 
eral living  authors  show  great  discrepancies,  whether  in  respect  to  the 
proportion  of  cases  detected  in  long  series  of  autopsies,  or  in  regard 
to  the  number  of  tubercular  tubes  discovered  in  operations  for  the 
removal  of  diseased  appendages.  Of  all  parts  of  the  female  genital 
tract,  the  tube,  no  doubt,  is  the  most  often  aft'ected. 

Tuberculosis  may  involve  the  Fallopian  tube  long  before  pubert}'. 
Dr.  W.  C.  Chaffey  has  described  a  case  where  a  child  aged  four  died 
with  tubercle  in  the  lungs  and  abdominal  organs.  The  Fallopian 
tubes  formed  two  nodular  masses,  each  about  the  size  of  a  filbert; 
the  tubal  wall  bore  caseous  deposit  on  its  inner  aspect,  l^r.  Quarry 
Silcock  detected  a  similar  condition  in  a  child  aged  five,  who  died 
of  tubercular  meningitis  folloAving  cough  and  otorrho?a ;  the  lungs 
and  ])Pritoneum  were  also  involved,  and  the  Fallopian  tubes  were 
enormously  distended  Avith  caseous  material.  These  two  cases  are  of 
(dinical  importance,  as  they  may  throw  light  on  the  significance  of 
tubercular  salpingitis  in  virgins.  Vt\\  Cullingworth  states  that  tubal 
disease  in  the  virgin  is  generally,  if  not  always,  tubercular:  in  such 
subjects,  it  is,  at  any  rate,  very  frequently  tubercular,  and  then  often 
appears  as  though  primary.  Nevertheless,  as  in  Chaffey  and  Silcock's 
cases,  in  infancy  the  patient  may  have  suffered  from  tubercle  elsewhere. 
An  organ  primarily  involved  may  recover  fiom  the  tubercular  affection. 


794  SYSTEM  OF  GYNECOLOGY 

A  secondary  deposit  in  the  tube  may  presumably  remain  latent  until 
puberty. 

Infection  of  the  tube  in  a  patient  already  tubercular  can  well  be 
understood.-  Jani  found  the  tubercle  bacillus  in  the  mucosa  of  a  tube 
from  a  patient  who  had  succumbed  to  chronic  phthisis  and  tubercular 
disease  of  the  intestine :  the  tube  was  perfectly  healthy.  Thus  the 
specific  germ  may  be  widely  diffused  without  necessarily  involving 
every  structure  to  which  it  pays  a  visit.  The  tube  may  be  invaded 
and  infected  through  the  circulatory  system.  Tuberculosis  of  the 
peritoneum  and  intestines  is  a  well-recognised  source  of  the  disease  in 
question.  Invasion  of  the  tube  from  the  lower  part  of  the  genital  tract 
is  rare. 

Pathologists  seem  fairly  agreed  that  the  Fallopian  tube  may  be  the 
seat  of  primary  tubercle  ;  but  in  any  suspected  case  we  must  bear  in  mind 
the  qualification  made  above  in  reference  to  Chaffey  and  Silcock's  obser- 
vations. Martin  and  Orthmann,  writing  in  1895,  assert  their  belief  in 
direct  infection  from  without,  the  vagina  and  uterus  escaping  damage 
from  the  germ.  The  bacilli  may  be  introduced  by  instruments,  by  the 
explorer's  finger,  and,  it  is  believed,  by  the  seminal  fluid  in  coitus. 
Whitridge  Williams,  on  the  other  hand,  does  not  think  that  it  has  ever 
been  satisfactorily  proven  that  genital  tuberculosis  occurs  as  the  result  of 
infection  by  coitus.  Menge's  case  is  attributed  to  this  cause,  chiefly  on 
the  strength  of  the  fact  that  the  disease  appeared  shortly  after  marriage. 
The  husband,  it  is  true,  "'was  known  to  have  genital  tuberculosis,"  but  he 
"  refused  to  be  examined."  Of  course,  if  the  tubercular  history  had  related 
to  himself  and  to  his  relatives  only,  and  not  to  his  wife's  also,  Menge's 
theory  would  have  been  almost  proved.  I  find,  however,  that  Menge 
admits  that  the  patient's  father  had  succumbed  to  phthisis,  five  sisters 
had  died  at  an  early  age  and  were  reported  as  scrofulous ;  and,  above  all, 
the  patient  was  laid  up  when  six  years  old  with  ascites  and  some  visceral 
disease.  She  had  also  been  Subject  to  swollen  glands.  This  history 
implies  primary  infection  elsewhere  than  in  the  tube.  Tubercular 
pyosalpinx  was  no  doubt  detected,  and  the  peritoneum  was  studded 
Avith  tubercular  deposit.  The  apparently  complete  recovery  of  the 
patient  a  few  months  after  the  removal  of  the  tubes  is  no  proof  that  the 
primary  seat  of  tubercle  was  extirpated  ;  it  is  but  an  interesting  example 
of  the  disappearance  of  the  symptoms  of  tubercular  peritonitis  after  sim- 
ple opening  of  the  abdominal  cavity.  Penrose  and  I^eyea  definitely  state 
that  they  have  detected  primary  tuberculosis  of  the  tube  in  three  cases, 
and  their  diagnosis  was  made  or  confirmed  on  alxlominal  section.  The 
patients  seem  to  have  recovered.  Yet,  in  one  or  more  of  these  cases, 
older  deposits  of  tubercle  may  have  existed  in  other  organs. 

Dr.  VVhitridge  Williams  is  the  autlior  of  the  best  synoptic  work  on 
1  iibiMcjiIosis  of  tlie  female  genital  organs.  He  is  wisely  cautious  about 
the  f|uostion  of  primary  infection.  *'  The  majority  of  cases  are  secondary 
to  tul)erc,ulosis  elsewh(;re,  and  are  due  either  to  infection  from  the  blood 
or  the  neighbouring  organs.      P>en  in  the  apparently  primary  cases  it  is 


DISEASES    OF   THE   FALLOPIAN   TUBES  795 


impossible  to  exclude  blood  infection."  I  agree  entirely  with  Dr. 
Williams  in  his  cautious  decision. 

Patholorjy. — Hard  as  it  is,  for  evident  reasons,  to  procure  a  tulje  in 
the  earliest  stage  of  ordinary  salpingitis  for  examination,  it  is  still  harder 
to  obtain  evidence  of  the  initial  changes  in  the  tubal  tissues  after  tul)er- 
cular  infection.  The  bacillus,  as  above  noted,  has  been  seen  in  a  still 
healthy  tube  in  a  phthisical  subject.  Schramm  gives  a  good  description 
of  incipient  salpingitis  due  to  tubercle.  I  have  always  found  that, 
with  important  modifications,  advanced  cases  resemble  advanced  salpin- 
gitis of  other  kinds.  As  I  find  in  ordinary  inflammation  of  the  tube, 
the  epithelium,  according  to  Schramm,  is  not  shed  even  when  the  tuber- 
cular disease  is  already  definite.  The  cells  swell  and  sometimes  lose 
their  cilia,  but  they  are  slow  to  fall.  The  essential  primary  change  is  a 
diffuse  cell-growth  of  lymphoid  and  epithelioid  character  in  the  plicae, 
which  become  greatly  SAVollen.  Cheesy  metamorphosis  of  this  cell- 
growth  speedily  follows,  the  change  beginning  in  the  nuclei  of  the 
epithelioid  cells.  Schramm  notes  that  the  epithelium  at  first  appears 
swollen  ;  and  the  nucleus,  greatly  enlarged  and  spherical,  fills  up  nearly 
the  whole  breadth  of  the  cell.  This  change,  however,  is  precisely  what  I 
have  seen  in  ordinary  chronic  salpingitis.  It  is  represented  in  Fig.  197, 
p.  787.  The  patient  in  this  instance  was  free  from  any  sign  of  tuber- 
cular disease,  and  remained  so  two  years  after  the  parts  were  removed. 

"When  caseation  takes  place  Schramm  finds  that  the  epithelium  disap- 
pears. Thus  its  destruction  is  a  secondary,  and  almost  a  purely  passive 
process,  which  I  make  out  to  be  the  case  in  ordinary  salpingitis.  The 
diffuse  cell-growth  invades  the  muscular  coat.  The  thickening  and 
subsequent  breaking  down  of  the  infiltrated  tissues  is  a  process  which  is 
easy  to  observe ;  it  is  seen  in  tubes  where  the  disease  is  more  advanced 
than  in  Schramm's  specimens.  In  Minister  and  Orthmann's  fine  drawings 
of  chronic  tubercular  salpingitis  the  appearances  are  much  the  same  as 
in  the  chronic  non-tubercular  form,  shown  in  Fig.  200,  p.  790.  There 
are  the  same  cyst-like  spaces  lined  with  epithelium.  There  is,  of  course, 
this  essential  distinction,  that  the  stroma  in  Miinster's  specimens  is  not 
only  subject  to  small-celled  infiltration,  as  in  uncomplicated  salpingitis, 
but  it  is  also  infested  with  giant  cells  and  other  characteristic  elements 
of  tubercular  disease.  Thus  precise  observation  shows  that  both  in  the 
earlier  and  later  stages  tuberculosis  of  the  tube  is,  to  say  the  least, 
intimately  allied  with  salpingitis. 

I  think  that  great  attention  should  be  paid  to  Schramm,  ^Minister, 
and  Orthmann's  researches;  since  they  show  that  in  the  early  stage  of 
tubercular  disease  of  the  tube  it  is  the  mucous  membrane  and  adjacent 
tissues  that  are  first  attacked,  and  that  the  disease  is  inflammatory —  in 
facta  form  of  salpingitis.  Martin  and  Orthmann  find  "acute  catarrh" 
in  acute  tuberculosis  of  the  tube,  whilst  the  chronic  form  of  the  same 
disease,  if  the  ostium  be  closed,  is,  according  to  their  researches,  practi- 
cally suppurative  salpingitis  or  pyosalpinx.  Whitridge  Williams'  fifth 
case  is  a  possible  exception ;  the  entire  tubal  mucous  membrane  was 


796  SYSTEM   OF  GYNECOLOGY 

stiidded  Tritli  miliary  tubercles  of  very  small  size,  but  no  accompanying 
inflammatory  change  could  be  detected.  Perhaps  after  all  this  is  the 
earliest  stage  of  tuberculosis  of  the  tube.  The  specific  cell-growth  in- 
vading the  mucosa  speedily  irritates  surrounding  tissues,  and  salpingitis 
is  the  result.  On  the  other  hand,  previous  inflammation  assuredly 
renders  the  tube  more  liable  to  be  damaged  by  the  tubercle-bacillus. 
As  in  tubercular  disease  of  the  epididymis  and  testis,  gonorrhoea  cer- 
tainly disposes  the  tube  to  infection  from  the  tubercle-bacillus.  This 
subject  is  familiar  to  the  bacteriologist,  and  mixed  infection  has  already 
been  recognised. 

"When  tubercular  peritonitis  exists,  invasion  of  the  tube  from  with- 
out is  easy  to  understand.  So  long  as  the  serous  coat  alone  is  involved 
the  disease  is  tubercle  on  the  tube  rather  than  tubercle  of  the  tube. 
The  deeper  coats,  however,  are  soon  invaded.  I  have  frequently  ex- 
amined such  tubes  and  never  found  inflammatory  changes  absent. 

The  naked-eye  changes  are  not  hard  to  detect  Avhen  the  tubercular 
disease  is  advanced.  The  tube  assumes  the  characters  seen  in  severe 
pN'osalpinx ;  its  dilated  cavity  nearly  always  contains  pus.  The  coats, 
much  thickened,  show  abundant  cheesy  deposit.  Free  adhesions  to 
adjacent  structures  are  the  rule.  Atrophic  fibroid  changes  have  been 
noted  by  some  writers.  The  tubercular  tube  becomes  extremely  tortu- 
ous and,  if  unobstructed,  remains  so. 

Symptoms  and  Dku/nosis.  —  When  a  history  of  tubercle  exists  diag- 
nosis is  not  usually  difficult;  but  Avheu  chronic  inflammation  of  the 
appendages  occurs  in  phthisical  subjects  and  in  patients  with  ample 
evidence  of  tubercle,  the  tubes  may  remain  unaffected  by  the  specific 
germ.  Hence  salpingitis  in  tubercular  patients  must  not  be  recklessly 
reported  as  tubercular. 

The  presence  of  a  tender  swelling  in  one  or  both  lateral  fornices  in 
a  tubercular  subject  is  fair  evidence,  I  admit,  of  disease  of  the  tube  clue 
to  the  general  infection.  Tubercular  salpingitis  is  often,  I  find,  a  very 
chronic  disease,  less  painful  than  the  non-tubercular  form.  Some  writers 
speak  of  pain  as  a  special  feature ;  but  this,  I  believe,  is  due  to  strong 
adhesions  which  interfere  with  neighbouring  organs.  Ultimately  the 
condition  is  the  same  as  in  neglected  pyosalpinx  from  other  causes,  and 
fistulas  discharging  pus  aggravate  the  patient's  condition.  The  ill 
health  may  at  first  cause  amenorrhoea.  As  a  rule,  however,  menstrua- 
tion is  profuse  and  painful,  a  symptom  caused  in  many  instances,  I  be- 
lieve, by  tubercular  changes  in  the  endometrium.  T.  S.  Cullen  (9a.) 
finds  that  "there  may  or  may  not  be  irregularity  of  menstruation"  in 
the  disease  which  he  describes.  He  finds  that  it  is  generally  secondary 
to  tuberculosis  of  the  tubes.  Ascites  is  very  frequent  in  tubercular 
peritonitis ;  hence  when  pelvic  exploration  in  a  young  subject  with 
ascites,  not  due  to  visceral  disease,  exhibits  evidence  of  enlarged  or 
inflamed  tubes,  these  structures  are  very  probably  tubercular. 

Evidence  of  gonorrluxjal  infection  added  to  symptoms  and  clinical 
records  indicating  tubercle  of  the  tube  greatly  increases  the  probability 


DISEASES   OF   THE  FALLOPIAN   TUBES 


797 


of  the  latter.  In  one  case  where  I  operated  this  kind  of  infection  was 
admitted  by  the  patient's  husband,  in  a  second  it  was  self-evident.  The 
pathology  of  this  complication  is  discussed  above. 

Treatment.  —  When  the  disease  is  apparently  confined  to  the  tube  the 
removal  of  the  morbid  structure  is  decidedly  indicated.  The  extirpation 
of  an  active  focus  of  tubercle  is  very  advisable. 

In  more  doubtful  cases  exploratory  incision  is  quite  justifiable.  In 
many  cases  of  disseminated  tubercle  the  opening  of  the  peritoneum  proves 


LJJ. 


Mix 


n.Urt. 


Fig.  203. —Tubes  and  uterus  from  a  patioiit  who  died  of  phthisis  throe  years  after  incision  of  peri- 
toneum infected  with  tubercle.  (See  Trans.  Obsi.  Soe.  vol.  xxxi.  p.  '217,  and  vol.  xx.xiii.  p.  186.) 
li.FJ.,  L.F.t.,  Riffht  and  left  Fallopian  tubes.  Ut.  cat:,  Uterine  cavity.  A  bristle  passed  into 
each  tube.     E.Uit.,  L.Uri.,  Ei^ht  and  left  ureter.      Vao.,  Upper  part  of  vagina.     Ur.,  Urachus, 

abnormal. 

in  itself  beneficial.  In  two  cases  in  which  I  incised  a  tubercular  peri- 
toneum, but  did  not  remove  the  diseased  appendages,  the  abdominal 
symptoms  subsided.  One  patient  died  of  phthisis  three  years  later; 
the  tubes  were  found  diseased,  yet  in  a  quiescent  condition  (Fig.  203). 
The  other  is  still  living,  four  years  after  the  operation ;  she  presents 
practically  no  objective  or  subjective  pelvic  symptoms  :  one  knee  remains 
weak  from  an  attack  of  synovitis  which  occurred  during  convalescence 
from  the  o]ieniti(in. 

Hydatid  Disease  of  the  Tube.  —  'M.  Doleris  {Tax  (pin^cologie  1896,  p. 
97)  recently  operated  on  a  butcher's  wife,  successfully  removing  both  her 


79S  SVST£J/   OF  GYAL-ECOLOGY 

tubes,  which  formed  a  pair  of  large  convohited  tumours  stuffed  with 
hydatid  cysts. 

Actinomycosis  of  the  Tube.  —  This  disease  has  been  more  talked 
about  than  observed,  as  it  was  the  cause,  a  few  years  since,  of  a  dispute 
between  two  authors.  There  can  be  no  doubt  that  in  Zemann's  case, 
so  often  quoted,  the  tube  was  the  seat  of  actinomycosis.  Zemann's 
report  is  thus  summed  up  by  Dr.  Illich  in  his  recent  monograph  on 
actinomycosis :  — 

'■  A  cook,  aged  forty,  taken  ill  with  symptoms  of  peritonitis.  Death 
after  meningitis  had  set  in.  A  few  coils  of  intestine  were  found  bound 
by  a  firm  and  widely  diffused  deposit  to  the  right  tube,  Avhich  was  con- 
verted into  a  sac  as  thick  as  a  finger,  full  of  pus  and  lined  with 
granulation  tissue  containing  actinomyces.  Metastases  in  brain,  lung, 
and  liver.  The  author  (Zemann)  traces  the  infection  to  the  genitals. 
Israel  s  aspects  that  the  infection  more  probably  proceeded  from  the 
intestine.  The  deposit  above  mentioned  indicates,  in  our  opinion,  the 
way  of  infection."  The  fungus  was  only  found  in  the  tube,  and  not  in 
the  metastases,  a  fact  which  would  seem  to  favour  Zemann's  opinion. 
Illich,  however  (1892),  stated  that  in  no  case  of  actinomycosis  of  the 
abdomen,  published  since  Zemann's  report  (1883),  has  there  been  the 
slightest  evidence  of  infection  through  the  genitals.  Sir  T.  Grainger 
Stewart,  nevertheless,  writing  in  1893,  brings  forward  evidence  which 
we  must  not  disregard.  In  his  case  the  patient  died  with  symptoms 
of  ursemia,  and  both  ovaries  were  infected  with  the  parasite;  colonies 
of  actinomyces  Avere  found  in  the  pus  which  filled  a  dilated  portion  of 
the  right  Fallopian  tube.  Stewart  concludes  that  the  mode  of  entrance 
was  by  the  vagina  and  uterus.  "  The  strict  localisation  of  the  disease 
on  the  right  side  to  the  ovary,  and  the  presence  of  the  parasite  in  the 
corresponding  Fallopian  tube,  afford  practically  conclusive  proof  that 
the  disease  had  spread  along  the  tube."  In  a  patient  aged  thirty-six, 
under  Illich's  observation,  a  mass  was  felt  in  Douglas'  pouch.  An 
exploratory  operation  proved  disastrous.  This  seems  always  to  be  the 
case  in  peritoneal  actinomycosis,  as  the  disease  is  widely  diffused  before 
marked  symptoms  set  in.  A  cyst  containing  characteristic  deposit  was 
found  on  each  side  of  the  uterus.  It  is  not  stated  whether  these  cysts 
were  tubal,  in  fact  no  mention  is  made  of  the  tubes.  The  intestines, 
liver,  and  lungs  were  infectedwith  actinomycosis.  [  Vide  art.  "Actinomy- 
cosis," fiiyst.  of  Med.,  vol.  ii.  p.  81.] 

Should  actinomycosis  of  the  tubes  be  suspected,  he  must  follow 
Netter's  advice,  and  prescribe  large  doses  of  iodide  of  potassium.  That 
drug,  so  useful  when  tlie  same  disease  attacks  cattle,  has  cured  two 
cases  of  actinomycosis  of  the  lung  and  csecum  respectively  in  the  human 
subject.  Cart  of  Paris  (1894),  therefore,  maintains  that  we  must  trust 
to  iodides  rather  than  to  the  knife.  Ohoux  (189r»),  tliough  he  gives  full 
credit  to  Netter,  is  more  inclin(!d  to  rely  on  surgeiy  tlian  on  salts,  but 
he  brings  forward  no  clinical  evidence  to  support  his  prc^f'erence. 

Fibroma  and  Enchondroma.  — The  existence  of  a  solid  tumour  of  the 


DISEASES    OF   THE   FALLOPIAN   TUBES  799 

tube  which  can  be  strictly  placed  under  either  of  the  above  denomina- 
tions is  very  doubtful.  The  first  term  is  often  loosely  applied  in  Avorks 
on  the  pathology  of  the  female  organs,  liy  "fibroid"  many  writers 
mean  not  so  much  a  tumour  as  the  disease  where  a  myomatous  tumour 
has  developed  in  the  uterus.  Hence  it  is  natural  that  ''  fibroma,"  still 
a  purely  pathological  term,  should  be  sometimes  used  in  error  for 
"fibroid,"  a  word  which  is  now  generally  used  in  a  clinical  sense.  By 
"fibroma  of  the  tube,"  then,  certain  writers  really  mean  "myoma,"  a 
new  growth  of  which  something  will  presently  be  said. 

On  the  fimbriae  it  is  not  rare  to  find  small,  semi-transparent  bodies 
looking  and  feeling  like  fragments  of  cartilage.  Bandl  states  in  his 
text-book  that  he  has  observed  them :  he  speaks  of  them  as  "  connec- 
tive-tissue growths  hard  as  cartilage."  Mr.  F.  S.  Eve  has  reported  more 
explicitly  on  a  specimen  of  this  kind  of  growth.  "  Each  nodule  contains 
two,  three,  or  more  circumscribed  structureless  (except  for  the  occasional 
appearance  of  faint  lamination)  yellow  masses,  apparently  in  part  cal- 
cified ;  the  edges  of  some  of  the  nodules  are  crenated.  The  surround- 
ing connective  tissue  is  very  rich  in  large  round  cells.  Of  the  nature 
and  mode  of  origin  of  these  masses  I  can  offer  no  opinion.  They  are 
neither  cartilage  nor  bone."  The  specimen  is  preserved  in  the  patho- 
logical collection  at  the  Museum  of  the  College  of  Surgeons  (Xo.  4584  a). 
I  believe  that  they  are  identical  with  the  very  similar  bodies  found  in 
ordinary  papilloma  of  the  ovary,  which  cause  the  mass  to  feel  gritty.  In 
examining  Sir  Spencer  Wells'  case  of  papilloma  of  the  tube,  a  few  years 
before  Mr.  Eve  described  the  cartilage-like  bodies,  I  found  that  the  cells 
of  the  stroma  near  the  apex  of  a  papilla  resembled  cartilage-cells. 

Kossmann  and  AVhitridge  Williams  may  hold  that  the  above  facts 
confirm  their  opinion  that  true  papilloma  of  the  ovary  is  derived  from 
tubal  elements.  They  do  not  confirm  the  opinion  that  true  enchondroma 
of  the  tube  has  ever  been  seen. 

Tubal  Calculus  simulating  Tumour.  —  I  have  several  times  detected 
small  gritty  collections  of  deposit  in  inflamed  tubes,  and  noticed  that 
the  grit  often  adheres  firmly  to  the  mucous  membrane.  If  the  deposit 
happen  to  lie  near  the  fiml3ria3,  the  condition  might  be  confused  with 
the  morbid  appearances  detected  by  Eve.  The  truth  is,  however,  that 
such  deposit  is  not  cartilage,  nor  calcareous  matter  from  a  hypothetical 
degenerating  fibroma  of  the  tube.  It  is  essentially  calculous  in  nature. 
Dr.  T.  S.  Cullen  (9a)  describes  and  figures  an  S-shaped  calculus  nearly 
an  inch  long  which  he  found  in  an  inflamed  and  obstructed  tube. 

Myoma  of  the  Tube.  —  Seeing  that  the  tube  is  morphologically  a 
part  of  the  uterus,  and  that  its  walls  contain  dense  layers  of  muscular 
tissue,  it  is  perhaps  remarkable  that  it  is  hard  to  find  authentic  cases  of 
myoma. 

The  uterus  has  thick  walls,  and  the  development  of  a  myoma  from  a 
minute  spherical  body  to  its  well-known  advanced  forms  is  familiar  and 
easy  to  observe.  With  the  tube  it  is  different ;  the  walls  are,  in  absolute 
measurement,  thin.     A  tumour  corresponding  to  the  "interstitial  fibroid" 


8oo  SYSTEM   OF  GYN.-F.COLOGY 

of  the  uterus  must  soon  spoil  the  tube  by  growing  inwards  and  obliterat- 
ing the  canal,  or  at  least  rendering  it  too  much  deformed  to  carry  on  its 
functions.  On  the  other  hand,  it  may,  Ave  can  assume,  be  a  "  subperi- 
toneal fibroid  " ;  in  such  a  case  its  growth  would  not  affect  the  tube  so 
much. 

Most  of  the  reported  cases  of  myoma  of  the  tube  were  pedunculated, 
that  is,  of  the  subperitoneal  class.  In  any  of  these  cases  the  tumour 
may  have  developed  from  the  muscular  fibres  in  the  broad  ligament  at 
its  point  of  reflexion  over  the  tube,  and  not  from  the  muscular  coat  of 
the  tube.  Sir  J.  Y.  Simpson's  case  of  fibroid  tumour  of  the  tube  has 
been  repeatedly  quoted.  It  was  "of  a  size  equal  to  that  of  a  child's 
head."  On  inspecting  the  well-known  woodcut  in  his  Clinical  Lectures, 
it  will  be  seen  that  the  tumour,  which  was  attached  to  the  upper  aspect 
of  the  tube  by  a  pedicle  several  inches  long,  could  hardly  have  arisen 
from  the  walls  of  the  tube,  which  appear  perfectly  normal.  It  is  easy 
to  see  how  a  myoma,  developing  in  the  broad  ligament  over  the  tube, 
would  acquire  a  pedicle  consisting  of  a  part  of  the  ligament  itself,  and 
stand  out  free  from  the  tube.  The  same  observation  applies  to  the 
drawing  in  Keating  and  Coe's  recent  Avork,  described  as  *'  tibro-myoma 
of  tube  (jMuseum  of  the  College  of  Physicians  and  Surgeons)."  The 
peduncle  is  of  some  length  and  breadth.  No  clinical  history  is  given. 
Schwartz's  case  seems  similar  to  Simpson's.  At  the  operation  a  tumour 
"  as  big  as  an  egg  "  was  found  connected  by  a  pedicle,  as  thick  as  a  fore- 
finger, and  about  one  inch  long,  with  the  right  tube,  close  to  the  uterine 
end.  The  pedicle  was  ligatured  and  divided.  The  tube  itself  is  reported 
as  normal,  and  was  not  removed.  The  uterus  Avas  free  from  any  morbid 
sign.  The  patient  Avas  fifty-four,  and  the  menopause  had  not  occurred. 
It  is  hard  to  understand  how  a  relatively  large  tumour,  springing  from 
relatively  small  structure  like  the  tube,  could  have  grown  so  free  from 
the  latter  as  to  render  removal  possible  without  the  sacrifice  of  the  other- 
Avise  healthy  structure.  But  further  experience  may  prove  that  a  myoma 
developed  in  the  tubal  Avail  does  tend  to  grow  outwards  till  it  becomes 
more  or  less  free  from  the  parent  structure,  the  sole  ultimate  connec- 
tion V>eing  a  band  of  broad  ligament.  Such  a  change  is  quite  different 
to  Avhat  is  so  often  seen  in  subperitoneal  uterine  myoma,  and  I  doubt  if 
it  can  ever  be  authenticated.  In  Spaeth's  and  Prochownik's  case  there 
Avas  uniform  hypertrophy  of  the  muscular  coat  of  the  outer  part  of  the 
tube  rather  than  a  true  circumscribed  tumour.  The  disease  proved  to  be 
an  oval  mass  two  inches  long ;  the  tubal  canal  passed  an  inch  forward  into 
its  substance,  ending  in  a  blind  extremity  ;  the  ostium  and  fimbria)  were 
effaced.  The  patient  was  thirty -nine  years  old.  Pland  Sutton  reports  a 
ease  where  an  interstitial  myoma  of  the  size  of  a  Tangerine  orange  was 
found  in  the  walls  of  a  tube  at  the  junction  of  the  uterine  and  middle 
thirds. 

Lastly,  many  observers  have  mistaken  collections  of  tuberculous 
matter  and  inflammatory  changes  in  chronic  salpingitis  for  minute 
myomas.     In    myoma   of    the   uterus    irregular   hypertrophy   of    the 


DISEASES   OF   THE  FALLOPIAN  TUBES  80 1 

muscular  coat  of  the  tube  is  very  frequent;  Eeymond  has  recently 
shown  that  this  condition  is  associated  with  inflammation,  hence  he 
terms  it  "nodulo-follicular  salpingitis,"  not  "myoma  of  the  tube."  The 
follicular  change  is  at  least  purely  inflammatory. 

Cysts  of  the  Tube. — The  large  irregular  yellow  bullae  so  often  seen 
on  the  surface  of  tlie  tube  in  cases  of  uterine  myoma  are  not  true  cysts, 
but  dilated  lymphatics.  When  the  adjacent  tissues  are  divided  during 
an  operation  the  lymph  drains  away,  and  these  bullae  disappear.  The 
common  broad  ligament  cyst  occasionally  develops  above  the  tube,  or, 
more  accurately  speaking,  under  the  serous  coat  at  the  free  border  of 
the  tube.     I  have  described  a  characteristic  case  elsewhere. 

The  well-known  pedunculated  cysts  Avhich  are  so  frequent  near  the 
fimbriae  contain  clear  fluid  and  are  lined  with  endothelium.  The  largest 
is  the  pyriforra  "  hydatid  of  Morgagni " ;  with  its  morphology  and  devel- 
opment we  have  nothing  to  do  at  present :  it  never  forms  a  large  cystic 
tumour,  but  I  have  seen  it  as  large  as  a  Williams  pear.  I  find  that  it 
is  very  apt  to  undergo  hypertrophy  when  the  adjacent  structures  are 
diseased.  In  one  case  which  I  have  examined  its  walls  had  undergone 
calcareous  degeneration.  The  ovary  was  cystic,  with  twisted  pedicle. 
In  a  case  of  attempted  cure  of  an  ovarian  cyst,  by  drainage  and  sub- 
sequent removal  of  the  cyst,  I  found  that  the  hydatid  of  jNIorgagni  was 
greatly  hypertrophied ;  its  pedicle  was  six  inches  long,  and  a  vessel  of 
considerable  size  ramified  on  its  surface.  The  cyst  itself,  though  so 
elongated  as  to  measure  several  inches,  was  narrow,  so  that  it  held  but 
little  fluid.  Ott  figures  a  "hydatid"  several  times  as  large  as  the 
adjacent  ovary,  which  was  itself  "three  times  the  normal  size."  The 
"hydatid"  has  connective-tissue  walls  with  endothelial  lining.  There 
was  chronic  inflammatory  disease  of  the  corresponding  appendages,  and 
tubal  pregnancy  on  the  opposite  side.  Professor  Sanger  has  recently 
described  a  most  remarkable  case,  where  two  masses  of  cysts  and  solid 
growths  sprang  each  from  a  pedicle  which  was  evidently  an  abnormal 
fimbria.  He  has  kindly  permitted  me  to  reproduce  Dr.  Uarth's  sketch 
of  the  specimen,  taken  when  it  was  fresh.  The  uterus  and  opposite 
appendages  were  included  in  the  sketch  (Fig.  204)  so  as  to  display  the 
relations  of  the  tumoui-.  The  patient  was  twenty -six;  after  delivery 
an  irregular  tumour  could  be  seen  under  the  relaxed  abdominal  walls. 
Four  months  later  it  was  removed  as  it  had  grown  larger.  The  two 
fimbriae  were  simply  ligatured  with  silk  and  divided.  The  left  append- 
ages, whence  the  growths  sprang,  were  replaced,  being  otherwise  per- 
fectly normal,  as  were  the  right  tube  and  ovary.  The  patient  recovered 
and  became  pregnant  again.  The  masses  were  of  different  colours  — 
white,  yellow  or  deep  red.  The  more  solid  were  made  up  of  mucoid 
tissue,  the  cysts  bore  no  epi-  or  endothelium,  hence  they  probably  repre- 
sented a  degenerative  change,  mucoid  tissue  having  broken  down.  They 
bore  no  relation  to  the  "  hydatids  "  common  in  their  neighbourhood.  The 
entire  growth  Avas,  Silnger  believes,  of  congenital  origin. 

Minute  thin-walled  cvsts  are  often  seen  on  the  surface  of  the  tubal 

3f 


802 


SyST£M   OF  GYNECOLOGY 


mucous  membrane  ^\'ithin  the  ostium.     Their  precise  pathological  import 
has  been  much  disputed. 

Dermoid  Tumours  of  the  Tube.  —  Thirty  years  ago  Dr.  Eitchie  re- 
ported a  case  of  tumour  in  a  tube  attached  to  a  cystic  ovary.  The  cyst 
was  "  as  large  as  a  plum ;  it  contained  four  loculi  which  were  origi- 
nally filled  with  a  creamy  fluid.  Each  loculus  was  lined  with  a  serous- 
looking  membrane,  studded  at  intervals  with  projecting  dendritic  growths 
absolutel}"  similar  to  those  so  frequently  met  with  in  ovarian  cysts. 
Besides  this  the  tumour  contained  a  plate  of  true  bone,  one  and  a  half 


Fig.  204.  —  Cystic  flbromyoma  of  the   fimbria;  (Siin^er).     a,  h,  FimbriiB  forming  pedicles  to  tlie  cysts; 

c,  ostium  of  the  tube. 


inches  long  by  about  half  an  inch  broad."  I  cannot  find  out  what 
became  of  this  specimen.  Dr.  Ritchie  called  it  a  dermoid  cyst,  but  his 
description  of  its  interior  suggests  papilloma  and  ossification.  "  Dendritic 
growths  "  are  not  often  associated  with  dermoid  cysts.  Treub  believes 
that  a  tumour  which  he  removed  from  the  tube  was  dermoid,  but  it 
is  highly  improbable  that  a  dermoid  tumour  can  develop  in  tubal 
tissue  proper.  On  the  other  hand  ovarian  dermoids  have  strange 
peculiarities.  I  can  well  conceive  how  a  tumour  of  that  familiar  class 
could  contract  very  intimate  adhesions  to  the  tube  so  as  to  deceive  the 
observer.  Old  pus  and  r-heesy  matter  in  the  tube  may  also  simulate  the 
greasy  material  which  fills  many  dermoids. 

In  sliort  there  is  no  sound  evidence  that  a  dermoid  tumour  of  the 
tube  has  ever  been  seen. 

Lipoma  of  the  Tube.  —  I  have  detected  true  adipose  tissue  under 


DISEASES   OF   THE  FALLOPIAN  TUBES  803 

the  mucous  membrane  of  absolutely  healthy  tubes  in  young  subjects. 
There  would  appear,  then,  to  be  no  reason  why  a  lipoma  should  not 
develop  in  the  substance  of  the  tube,  even  close  to  the  uterus.  On  the 
other  hand,  it  has  long  been  known  that  a  distinct  layer  of  fat  is  some- 
times to  be  seen  between  the  folds  of  the  broad  ligament  just  below  the 
outermost  part  of  the  tube,  following  the  ovarian  fimbria.  Eokitansky  first 
recognised  this  condition.  In  1889,  in  examining  a  dermoid  ovarian  cyst, 
I  found  a  considerable  amount  of  dense  granular  fat  between  the  layers 
of  the  broad  ligament  (15e).  In  a  specimen  of  papillomatous  ovarian  cyst, 
which  I  removed  in  1894, 1  found  an  oval  fatty  tumour  hanging  by  a  dis- 
tinct pedicle  from  the  Fallopian  tube  close  to  the  root  of  the  ovarian  fim- 
bria (loQ.  It  measured  barely  half  an  inch  in  long  diameter.  It  arose,  1 
believe,  from  the  broad  ligament  fat  just  described,  or  from  an  extension 
of  that  fat  to  the  subserous  tissue  of  the  peritoneum  covering  the  tube. 

Parona's  case  is  of  some  importance :  it  is  too  often  quoted  at  second 
hand.  The  patient  was  thirty-seven  ;  removal  of  the  appendages  for  the 
relief  of  a  uterine  fibroid  was  undertaken.  The  left  were  low  down  and 
their  removal  was  difficult :  the  right  ovary  and  tube  bore  the  lipoma;  and 
as  they  lay  high  upon  the  myomatous  uterus  they  Avere  easily  amputated. 
The  lipoma  weighed  a  little  under  3  oz.,  and  measured  3^  inches  in  long 
diameter.  The  ovary,  "  of  normal  size  and  texture,"  was  attached  to  the 
tumour  by  a  kind  of  pedicle  formed  of  two  layers  of  peritoneum  which 
invested  the  lipoma ;  the  mesosalpinx,  in  fact,  had  been  opened  up.  The 
fimbriated  extremity  of  the  tube  showed  clearly  at  one  end;  the  tube  was 
partially  sunken  in  the  parenchyma  of  the  tumour.  On  microscopical 
examination  "  traces  of  the  wall  of  the  tube  with  characteristic  ciliated 
epithelium  were  seen  mixed  up  with  the  adipose  tissue  of  the  lipoma." 
Parona's  own  words  state  that  the  tube  "  con  adatte  sezioni  del  tumore 
si  trovo  parzialmente  sepolta  nel  parenchima  del  esso.  Cio  fii  accertato 
con  ripetute  preparazioni  microscopiche  mediante  le  quali  si  rilevarono 
traccie  di  parete  dell'  ovidotto  col  caratteristico  epitellio  vibratile  tramezzo 
al  tessuto  adij^oso  del  lipoma."  In  an  illustration  the  tube  is  shown  laid 
open,  winding  on  the  surface  of  the  lipoma  in  which  its  lower  part  only 
is  "partially  buried."  The  end  of  the  original  quotation  just  given 
might  imply  that  the  lipoma  had  really  arisen  in  the  substance  of  the 
tubal  wall.  If  so,  however,  the  upper  or  free  border  of  the  wall  would 
surely  have  been  invaded,  so  that  the  imbedding  would  be  much  more 
complete.  I  suspect  that  the  fat  arose  in  the  folds  of  the  broad  liga- 
ment, as  in  my  ovm  case,  and  that  it  afterwards  invaded  the  tube ;  but 
even  in  that  case  Parona's  expression  "  tramezzo  al  tessuto  adiposo  " 
does  not  explain  whether  an  entire  piece  of  tube,  muscular  coat,  and 
epithelium  was  seen  mixed  up  with  the  fat,  or  whether  the  histological 
elements  of  the  tube,  muscular  fibres,  and  epithelial  cells  were  actually 
scattered  amid  the  fat  cells  of  the  tumour. 

Papilloma  of  the  Fallopian  Tube.  —  INIuch  diversity  of  opinion  still 
exists  respecting  ])apilloma  and  cancer  of  the  tube.  Only  by  a  patient 
examination  of  existing  records  can  we  establish  the  diagnosis  and  pa- 


8o4  SYSTEM   OF  GYNAECOLOGY 

thology  of  these  important  diseases.  I  therefore  feel  compelled  to  intro- 
duce the  essential  part  of  these  records,  trusting  that  ray  report  will  not 
be  so  brief  as  to  be  obscure,  nor  so  long  as  to  be  wearisome. 

In  1879  I  applied  the  term  papilloma  to  an  exuberant  morbid  growth 
which  lay  in  the  interior^  of  a  Fallopian  tube.  Several  observers, 
especially  in  Germany  (29a),  agree  with  me  as  to  nomenclature.  That 
distinguished  pathologist,  Mr.  Bland  Sutton,  on  the  other  hand,  classes 
such  tumours  under  "  adenoma."     Here  at  once  is  matter  for  debate. 

In  case  o  in  the  tables  I  detected  patches  of  the  disease  in  its  earliest 
stages.  It  appeared  as  a  small  wart.  The  microscope  showed  (Fig.  205) 
that  its  structure  was  essentially  papillomatous. 
The  elevations  are  not  glands,  nor  are  they 
tubal  folds.  The  section  was  made  through 
a  portion  of  the  diseased  tube,  where  the  folds 
had  long  been  effaced.  The  epithelium  of  the 
tubal  mucosa,  as  I  have  already  shown  in  the 
observations  on  salpingitis,  is  not  necessarily 
shed,  even  after  all  the  plicae  are  effaced 
.      ^  (Fig.  197,  p.   787).     When  that  change  has 

Fig.  205. — Microscopical  section  of     ^'='  i-,i-  tji  •,  o 

a  papillomatous  outgrowth  from    OCCUrrCd,    aS    111    thlS    and    OtllCr    lUStauCeS    01 

the  left  tube  (.case  3}     The  papilloma  of  the  tubc,  there  may,  therefore, 

papillie  are  very  fine,  like  villi,     ^     ^     .  .    '     ,.  it  • 

and  bear  cMumnar  epithelium ;     remain    plenty   of    epithelium    tO    clcvelop    luto 

one  papilla  is  branched.  ^,-|^-  ^^hich  are  esscutially  epithelial  growths. 

I  made  these  researches  in  January  1888,  and  demonstrated  sections 
at  a  meeting  of  the  Pathological  Society  of  London  a  month  later. 
Next  year  appeared  some  perfectly  independent  investigations  by  Eberth 
and  Kaltenbach  (Tables,  Carcinoma  of  Tube  No.  3).  In  examining  a 
tubal  growth  which  proved,  clinically  at  least,  to  be  cancerous,  they 
found  that  in  its  earliest  stages  it  was  made  up  of  true  papillae.  As  in 
my  case  (No.  3),  the  papillae  appeared  at  first  sight  like  villi.  In  parts 
the  tubal  mucosa  looked  like  velvet,  owing  to  collections  of  numerous 
long  and  short  branched  villi.  At  more  healthy  points  on  the  mucosa 
there  were  evidences  of  incipient  papillary  growths.  On  microscopical 
examination  the  entire  process  of  growth  was  found  to  correspond  to  the 
development  of  ridges  of  papillae  on  the  skin.  The  increase  of  the  stroma, 
or  sub-epithelial  connective  tissue,  was  secondary,  a  fact  which  tallies 
with  my  own  observations  on  No.  3  papilloma.  This  fact  must  be  borne 
in  mind  when  the  opinion  that  the  growth  is  adenoma,  not  papilloma, 
comes  to  be  considered.  Zweifel  (Tables,  Carcinoma  No.  6),  in  1892, 
noted  that  these  growths  in  their  earliest  stage  were  villiform ;  more 
precisely  they  began  as  papillae,  as  is  above  explained.  The  question  of 
cancerous  degeneration  will  be  discussed  in  the  paragraphs  on  tubal 
carcinoma. 

When  I  applied  the  term  "papilloma"  to  case  1,  I  had  in  my  mind 
Hennig's  observation,  made  three  years  earlier,  that  hyperplasia  of  the 

1  Papillomatous  growths  on  the  serous  coat  are  not  included  in  this  class,  which  is  con- 
fined to  papilloma  in  the  tube. 


DISEASES   OF  THE  FALLOPIAN   TUBES  805 

tubal  mucous  membrane  passed  into  polypoid  growth  (as  in  some  of  the 
warts  in  No.  3)  through  the  successive  stages  of  warty  and  papillary 
tumours  ;  these  transitional  forms  being  often  found  side  by  side  in 
dropsical  tubes.  I  had  already  detected  warty  growths  in  a  dilated  and 
obstructed  tube  which,  together  with  the  adjacent  ovary,  had  been  sub- 
ject to  long-standing  inflammation.  I  believe  that  these  papillomas  arc 
allied  to  the  condylomas  and  warts  seen  on  the  external  genitals  irritated 
by  venereal  discharges.  Doleris  is  of  precisely  the  same  opinion.  In 
his  case,  No.  5,  Tables  of  Papilloma,  the  patient  had  suffered  from  a 
venereal  discharge.  In  No.  1  this  complication  may  be  discarded,  but 
the  history  of  pelvic  inflammation  was  distinct.  In  all  the  six  cases  in 
the  tables  there  is  good  reason  to  suspect  that  the  disease  Avas  of  inflam- 
matory origin,  a  sequel  of  salpingitis.  Positive  evidence  is  alone  wanting 
in  No.  4,  Dr.  Walter  admitting  that  the  earlier  history  of  the  patient's 
illness  could  not  be  determined. 

Mr.  Bland  Sutton's  opinion  that  these  growths  are  adenoma  is  based 
partly  on  the  theory  that  true  glandular  structures  exist  in  the  tube, 
and  partly  on  a  painstaking  re-examination  of  the  growth  in  No.  1. 
That  specimen,  however,  represented  an  advanced  condition.  I  have 
already  explained  that  the  first  stage  in  the  development  of  a  papilloma 
is  represented  by  a  villus  or  papilla,  consisting  chiefly  of  epithelium. 
The  great  increase  of  the  stroma,  which  makes  the  tumour  assume  the 
appearance  of  a  succulent  adenoma,  is  late  and  quite  secondary.  Sanger 
and  Barth  make  out  two  forms  of  the  disease,  "  simple  papilloma  "  and 
"cystic  vesicular  papilloma  "  ;  No.  1  being  of  the  second  class :  but  both 
are  held  to  be  essentially  papillomatous. 

The  well-known  solid  intracystic  ovarian  growths  are  not  inflamma- 
tory, but  are  glands  which  develop  in  the  ovary  just  as  hair  and  teeth  may 
develop  in  that  organ.  Mr.  Sutton  and  myself  both  believe  it  reasona- 
ble to  consider  adenomatous  non-malignant  ovarian  cysts  as  allied  to 
what  is  understood  by  the  term  "  dermoids."  In  any  case  they  are 
adenomas  and  not  associated  Avith  inflammation.  I  cannot  admit  unre- 
servedly that  papilloma  of  the  ovary  is  identical  with  papilloma  of  the 
tube;  clinically,  at  any  rate,  they  are  distinct,  but,  according  to  my 
observations,  both  diseases  begin  as  papillcB;  hence  both  are  papilloma. 
Whitridge  Williams  and,  more  emphatically,  Professor  Kossmann  declare 
that  papilloma  of  the  ovary  is  not  derived  from  parovarian  relics  as 
Coblenz,  Sutton,  and  myself  tend  to  believe,  but  from  tubal  elements 
(NebentubPHC'/sten ,  parasalpingeal  cysts).  At  present  all  Ave  have  to  bear 
in  mind  is  that  these  observers  admit  that  papilloma  occurs  in  connection 
Avith  the  tube. 

Bland  Sutton,  like  Hennig.  belicA'es  in  the  presence  of  glands  in 
the  tube.  His  arguments  Avill  be  found  in  his  Avell-knoAvn  toxt^book.  I 
myself  Avas  once  inclined  to  accept  the  gland  theory  without  hesitation. 
I  cannot,  hoAvever,  overlook  the  fact  that  some  of  the  most  recent  observers 
absolutely  deny  the  existence  of  any  structure  corresponding  to  a  gland 
in  the  Fallopian  tube.     Frommel,  Whitridge  Williams,  'M.  Dixon  Jones, 


8o6  SYSTEM   OF  GYX.-ECOLOGY 

and,  qviite  recentl}',  ]\[artiii  and  Sanger  in  their  text-book  on  Tubal  Dis- 
eases issued  in  June  1895,  are  all  more  than  sceptical  about  the  exist- 
ence of  glands.  (See  observations  on  Sanger's  case  of  cancer  of  the  tube, 
No.  8  inCancer  Tables.)  Dr.  Berr}-  Hart,  in  the  chapter  on  the  Anatomy 
of  the  Female  Genital  Organs  in  this  Avork,  expresses  the  same  doubts. 
All  that  I  can  say  in  relation  to  my  subject,  which  is  the  nature  of  a  cer- 
tain tumour,  is  that  the  scepticism  about  the  presence  of  glands  in  the 
Fallopian  tube  prevents  me  from  believing  without  hesitation  that  the 
tumour  in  question  is  an  adenoma.  The  opinion  of  so  distinguished 
an  author  as  Bland  Sutton  must  not,  however,  be  set  aside  lightly.  If 
he  be  correct  adenoma  of  the  tube  may  occur.  Von  Recklinghausen 
denies  that  the  tubal  mucosa  is  furnished  with  normal  glands,  but  he  has 
detected,  chiefly  in  tubes  taken  from  the  bodies  of  old  women  who  had 
died  of  pneumonia,  and  the  like,  remarkable  glandular  structures  which 
he  considers  to  be  relics  of  the  Wolffian  body.  They  may  be  the  source 
of  Sutton's  adenoma. 

The  possibility  of  adenoma  developing  in  the  tube  cannot  affect  the 
evidence  which  I  and  others  have  long  since  brought  forward,  that  when 
seen  at  an  early  stage  the  tumour  in  question  is  always  found  to  consist 
of  a  papilla  or  villus.  Thus  Fig.  205  could  not  be  a  morbid  development 
from  one  of  Bland  Sutton's  glandular  diverticula.  Therefore  I  shall 
retain  the  term  "papilloma." 

There  are  two  features  of  high  interest  in  association  with  papilloma 
of  the  tube.  The  disease  is  known  to  assume  characters  apparently 
malignant,  though  the  after  history,  when  the  diseased  part  is  removed, 
may  prove  the  new  growth  to  be  innocent.  It  seems  equally  certain 
that  if  left  alone  the  papilloma  will  undergo  malignant  degeneration. 
In  the  second  place  remarkable  symptoms  have  been  observed,  as  result 
of  discharge  from  the  growths  in  instances  whe*re  the  ostium  or  the 
uterine  end  has  remained  unobstructed.  I  have  tabulated  six  cases 
which  have  been  under  close  observation.  In  two  (Nos.  1  and  4),  the 
ostium  was  open  and  the  peritoneum  was  full  of  fluid.  In  one  (No.  5), 
the  ostium  was  closed  and  the  uterine  end  patent ;  very  free  watery 
discharge  escaped  through  the  vagina  in  consequence.  In  two  (Nos.  2 
and  3),  the  tube  was  closed  at  both  ends,  and  there  was  neither  ascites 
nor  discharge.  No.  6  resembled  Nos.  1  and  4,  the  ostium  being  open, 
but  there  was  no  ascites. 

No.  1  was  a  patient  of  Mr.  Bickersteth's  of  Liverpool,  and  Sir  Spencer 
Wells  operated.  I  published  the  history,  with  a  full  pathok)gical  report 
in  1879,  and  is.sued  notes  of  the  after  history  seven  years  later.  This  is 
the  case  to  which  I  referred  at  the  beginning  of  these  observations  on 
papilloma  of  the  tube.  The  great  feature  of  interest  is  the  gloomy 
clinical  aspect  of  the  case  before  and  during  operation  in  1879,  as  com- 
pared with  the  after  history.  For,  in  spite  of  ominous  pleural  and 
peritoneal  effusions  containing  ugly-looking  cells,  and  notwithstanding 
the  presence  of  an  exuberant  new  growth,  and  the  impossibility  of  cutting 
through  the  Fallopian  tul^e,  at  the  opciration,  far  beyond  the  linuts  of  the 


DISEASES    OF   THE   FALLOPIAiV   TUBES  807 

growth,  no  recurrence  occurred.  Schroeder  in  1886  maintained  that  this 
case  was  evidently  malignant;  (See  also  observations  on  No.  3  in  the 
Tables  of  Cancer  of  the  Tube.)     On  14th  November  1895,  Mr.  Bicker- 

steth  wrote  to  me  saying,  "  Miss called  on  me  a  few  days  ago,  and 

I  never  saw  her  looking  better." 

The  patient  Avas  first  seen  by  Mr.  Bickersteth  in  October  1877.  She 
then  had  symptoms  of  inflammation  of  the  right  ovary  following  nienor- 
rhagia,  which  subsided  after  rest.  This  history  of  inflammation  must  be 
borne  in  mind;  it  is  common  to  all  the  cases  of  papilloma  (except  that  in 
No.  4  it  Avas  not  noted),  and  the  relation  of  this  morbid  growth  to 
inflammation  has  already  been  discussed.  The  clinical  and  pathological 
relations  of  adenoma  are  different.  In  ^March  1878  the  patient  had  an 
attack  of  pleural  effusion  on  the  right  side;  120  ounces  of  clear  fluid  were 
removed  by  tapping.  In  July,  9  pints  of  fluid  were  drawn  off  from  the 
abdomen,  which  had  become  swollen.  In  September,  13  pints  were 
removed  from  the  abdomen.  In  October,  100  ounces  were  drawn  off  on 
tapping  the  right  pleura.  In  January  1879,  the  abdomen  Avas  tapped  a 
third  time  and  16  pints  were  drawn  off.  These  accumulations  of  fluid 
and  the  five  tappings  Avere  not  accompanied  by  rise  of  temperature  or 
systematic  disturbance.  There  Avere  no  signs  of  cardiac,  hepatic,  or  renal 
disease. 

In  March  1879,  Avhen  the  patient,  a  thin  and  emaciated  maiden  lady, 
Avas  fifty  years  of  age.  Sir  Spencer  Wells  first  saw  her.  As  she  objected 
to  an  exploratory  incision  the  abdomen  Avas  tapped  for  the  fourth  time, 
and  22  pints  of  fluid  Avere  removed.  The  specific  gravity  of  the  fluid 
Avas  1022,  and  it  coagulated  almost  entirely  under  the  action  of  heat  and 
nitric  acid.  Its  scanty  flocculent  deposit  Avas  found  to  consist  of  large 
cells,  mostly  grouped  in  clusters  and  apparently  proliferating;  many  were 
distinctly  vacuolated:  similar  cells  had  been  found  in  the  pleural  fluid. 
I  examined  some  of  these  cells,  and  neA^er  saAv  any  structure  in  morbid 
fluids  that  more  thoroughly  suggested  malignanc}^;  and  at  that  date  I 
Avas  examining  ascitic  and  CA^stic  fluids  many  times  a  Aveek.  Since  then 
I  have  ceased  to  trust  the  evidence  of  solitary  cells  in  the  diagnosis  of 
malignancy.  The  incident  of  effusion  will  be  considered  in  association 
with  one  of  the  conditions  detected  after  the  operation. 

The  uterus  Avas  movable,  and  so  low  in  the  pelvis  that  the  cervix  laA' 
close  to  the  Aailva;  behind  that  organ  a  hard  nodular  mass  could  be 
detected.  On  April  28,  1879,  Sir  Spencer  Wells  operated.  The  peri- 
toneal cavit}^  contained  17  pints  of  amber-coloured  fluid.  A  tumour 
of  the  size  of  a  large  orange  lay  to  the  right  of  the  uterus  ;  it  Avas 
removed  together  Avith  the  right  OA^ary.  No  secondary  deposits  could 
be  found  on  the  peritoneum,  notAvithstanding  the  most  careful  search. 
Eecovery  was  rapid.  The  patient  suffered  from  an  attack  of  pleurisy 
four  months  later  Avithout  any  effusion.  Menstruation  had  ceased  for 
over  two  months  before  operation;  one  tube  and  ovary,  be  it  remembered, 
were  not  removed.  As  has  been  already  observed,  the  jtatient  Avas  Avell 
iu  the  autumn  of  1895,  sixteen  years  after  the  operation. 


8oS 


SYSTEM  OF  GYNAECOLOGY 


The  tumour,  no-win  the  jNhiseum  of  theEoyal  College  of  Surgeons  (Path. 
Series,  Xo.  4584)  consists  of  the  Fallopian  tube,  extremely  dilated,  with 
the  ovary,  iniaff ected,  beneath  it.  The  uterine  eii d  admitted  a  bristle  which 
could  be  passed  through  the  entire  tube  and  out  of  the  ostium.  The  fim- 
briae, short  and  thick,  were  still  to  be  seen ;  the  ostium  was  abnormally 
patulous.  Cauliflower  excrescences  sprouted  from  all  parts  of  the  mucous 
membrane;  they  were  covered  with  a  mucoid  material  which  issued  from 
the  ostium. 


Fio.  206.  —  Papilloma  of  the  ?"alloiiian  tube.  Case  1.  The  tubal  wall  has  been  divided  alonp;  its  upper 
border  and  turned  back,  exposing-  the  papillomatous  masses  springing  from  the  mucous  membrane. 
A  bristle,  entering  the  cut  uterine  end,  passes  along  the  tube  amidst  tho  growths,  and  emerges  at 
b,  the  ostium.  The  tube  is  undilated  as  far  as  a  ;  c,  ovary  ;  d,  small  ])cdunculated  cyst;  e,  cyst 
developed  amidst  the  papillomatous  growths. 

Here  I  must  pause  to  consider  the  pleural  and  peritoneal  effusions  in 
this  non-malignant  case.  So  far  as  innocent  ovarian  tumours  are  con- 
cerned, M.  Demons  of  Bordeaux  has  published  researches  of  great  value. 
He  has  seen  })]eural  effusion  in  9  out  of  50  cases  of  common  ovarian 
cyst.  One  of  liis  patients  had  an  ovarian  tumour  on  the  riglit  side  and 
free  effusion  into  both  pleurae.  Cancer  was  reasonably  suspected,  as  in 
the  case  of  tuljal  disease  now  under  considci-ation.  The  pleura  was 
tapped  several  times  on  both  sides  ;  but  the  fluid  rapidly  re-accumulated 
and  the  health  began  to  fail.  Demons  did  ovariotomy,  the  double 
effusion  disappeared  "like  magic"  and  never  returned.     He  attributes 


DISEASES   OF  THE  FALLOPIAN   TUBES  809 

the  pleural  effusion  to  lymphatic  obstruction  due  to  the  interference  of 
the  tumour  with  the  circulation  in  the  abdominal  lymphatics,  which 
arrest  extends  through  the  diaphragm  to  the  lymphatics  of  the  pleura. 
In  other  cases  Demons  observed  more  or  less  abundant  ascites.  Verneuil 
believes  in  the  lymphatic  obstruction  theory. 

In  this  case  of  papilloma  the  existence  of  lymphatic  obstruction  is 
hard,  if  not  impossible,  to  detect.  I  found  that  free  mucoid  material 
issued  from  the  ostium.  As  in  this  case  1  in  the  tables,  so  in  case  4 
there  was  ascites  ;  in  both  the  ostium  was  open.  Hence  it  is  reasonable 
to  believe  that  some  irritation  from  the  discharge  set  up  the  effusion. 
The  big  cells  indicated  more  than  lymphatic  obstruction.  Lucas- 
Championniere,  in  the  discussion  on  Demons'  communication,  stated 
that  he  found  pleural  effusion  with  or  without  ascites  most  frequent  in 
cases  of  proliferating  abdominal  tumours.  I  have  operated  on  free 
papilloma  of  the  ovary,  where  abundant  ascites  existed,  the  effusion 
disappearing  permanently  afterwards ;  hence,  I  fancy  that  the  effusion 
is  due  to  irritation  of  some  sort.  The  papillomas  in  one  of  my  cases 
seemed  too  small  to  obstruct  anything.  In  the  tubal  case  both  the 
peritoneum  and  one  pleural  cavity  suffered  from  this  irritation,  but  as 
the  phenomenon  of  abdominal  tumour  with  pleural  yet  without  peri- 
toneal effusion  did  not  occur  in  this  case,  it  need  not  be  discussed  here. 


Fio.  207.  —  Pa[iilloina  of  the  Fallopian  tube.     Case  1.    Sections  of  an  outgrowth  under  a  high  and  a  \o\t 
power.     (/,  I'apilla,  the  same  which  is  shown  more  highly  magnified  ;  h,  space  hned  with  epithelium. 

I  have  minutely  described  elsewhere  the  microscopic  appearances 
of  this  growth.  A  layer  of  columnar  epithelium  invested  the  whole  of 
the  outgrowths  which  made  up  the  tumour.  It  was  ciliated  at  certain 
points,  and  nowhere  invaded  the  stroma. 

The  arguments  in  support  of  my  original  opinion  that  the  new 
growth  was  in  this  case  a  true  papilloma  rather  than  an  adenoma,  have 
been  given  at  the  beginning  of  these  paragraphs  on  the  subject.  Sec- 
ondary increase  of  the  stroma  may  fully  account  for  the  ajipearances 
in  this  tumour.  It  may  account  for  the  large  cystic  spaces  lined  with 
epithelium  which  I  discovered  in  the  stroma  (Fig.  207,  6).  The  pajulhv; 
developed,  I  believe,  as  a  result  of  salpingitis.  The  spaces  would  in 
that  case  be  identical  with  those  which  so  often  develop  when  the 


8io  SYSTEM   OF  GYNAECOLOGY 

tubal  mucosa  becomes  inflamed. ;  the  manner  in  -whicli  they  form  has 
been  already  explained  (see  p.  788,  and  Fig.  200).  Bland  Sutton  com- 
pares the  tumour-substance  with  the  normal  tubal  mucosa  in  a  macaque 
monkey.  As  there  is  still  more  stroma  in  the  macaque's  tube  in 
health/  this  resemblance  would  imply,  not  that  the  tumour  was  an 
adenoma,  but  rather  that  it  Avas  a  pure  hj^pertrophy. 

The  clinical  features  of  case  2  are  sufficiently  explained  in  the 
appended  tables.  I  assisted  at  the  operation,  and  plainly  saw  that  it 
was  a  Fallopian  tube  that  Avas  removed.  The  ostium  was  closed.  The 
cavity  was  stuffed  Avith  rather  gritty  papillomatous  masses.  Unfortu- 
nately this  A^aluable  specimen  AA^as  accidentally  lost. 

Case  3  is  A'ery  suggestive.  At  the  beginning  of  these  observations 
I  have  noted  that  the  new  groAvth  could  be  detected  in  its  incipient 
form  as  a  papilla  (Fig.  205,  p.  804).  The  ovaries  and  tubes  had  \inder- 
gone  simultaneous  cystic  degeneration,  the  result  of  long-standing  in- 
flammatory disease;  and  papilloma  had  begun  to  develop  on  their  inner 
walls.  I  fully  discussed  these  changes  in  the  paper  referred  to  in  the 
tables,  and  I  shall  again  refer  to  this  case  in  speaking  of  Warnek's 
example  of  tubal  cancer  (No.  12,  Tables  of  Cancer  of  Tube). 

The  fourth  case  was  originally  recorded  by  Bland  Sutton.  Dr.  Walter 
informs  me  that  the  patient  did  not  recoA^er  from  the  operation.  Mr. 
Sutton  has  given  a  description  of  the  microscopical  appearances  of  the 
growth,  which  he  considers  to  be  an  adenoma.  I  must,  however,  dAvell 
on  one  sentence  in  his  obserA'ations ;  namely,  that "  the  specimen  differed 
from  Doran's  case  in  that  it  contained  a  far  larger  proportion  of  stroma." 
Hence  it  may  have  been  of  older  groAvth.  As  in  No.  1,  there  is  no  evi- 
dence as  to  Avhat  the  earliest  appearances  of  the  growth  might  have 
been.     The  ascites  and  patulous  ostium  cause  No.  4  to  resemble  No.  1. 

In  case  5  the  patient  Avas  a  public  singer  of  irregular  habits.  There 
Avas  a  long  history  of  vaginal  discharge,  attacks  of  pelvic  inflammation, 
carelessness  of  advice,  and  immoderate  sexual  indulgence.  In  May 
1888,  Avhen  straining  at  stool,  a  great  quantity  of  sero-sanguineous  fluid 
escaped  from  the  vagina.  The  discharge  continued  for  six  days,  often 
drenching  the  patient's  clothes.  Several  quarts  came  away.  A  week 
later  the  period  occurred  and  lasted  six  days,  then  the  free  discharge  re- 
commenced. The  pains,  Avhich  had  been  severe,  subsided.  The  abdomen 
Avas  almost  flat  throughout.  (Nos.  15  and  17  in  the  Cancer  Tables  pre- 
sented these  remarkable  symptoms  of  "  hydrops  proflviens.")  On  ex- 
amination a  SAvelling  Avas  found  in  each  fornix;  serous  fluid  was  seen 
to  issue  freely  from  the  os  uteri.  The  tubes  could  not  be  cathetoi'ised. 
Eleven  months  after  this  examination,  the  serous  discharge  having 
become  very  free,  M.  Doleris  operated.  The  left  appendages  were 
removed ;  they  were  much  altered  by  chronic  inflammation.     On  the 

1  Hero  wo  must  ho  oarofiil  in  vorifyiri'^  Mr.  Sutton's  roscirolics,  lest  the  tubes  of 
qiiadrurnana  ,solootf;(l  for  oxarninatif)n  as  normal  bo  rcially  discsascMl.  Monkeys  in  cap- 
tivity aro  vr!ry  oftfin  siokiy,  tlioir  vvoll-knovvii  sloi'ility  and  still  hotlor  known  sexual 
irritaliility  both  load  us  to  suspect  that  disoaso  of  tin;  {^oiiital  tract  must  ho  frequent. 


DISEASES    OF   THE   FALLOPIAN   TUBES 


right  side  was  a  tumour  adherent  to  intestine,  omentum,  and  the  pelvic 
wall.  Its  surface  was  pearly  white.  After  removal  it  was  found  to 
consist  of  the  right  Fallopian  tube.  From  its  inner  wall  grew  masses 
of  arborescent  vegetations  of  the  kind  usually  observed  in  papilloma. 
There  was  a  central  part  of  vascular  connective  tissue,  and  a  layer  of 
epithelium  on  the  surface.  At  certain  points  these  cells,  which  were 
cylindrical,  were  arranged  in  double  or  triple  layers  which  the  patholo- 
gists reported  as  suggesting  malignancy.  The  ostium  was  closed, 
the  uterine  end  remained  relatively  narrow,  bearing  no  papillomatous 
growths,  but  the  canal  was  patent  and  dilated.  The  operation  was 
performed  in  July  1889.  Doleris  informed  me,  in  a  letter  dated  23rd 
October  1894,  that  there  had  been  no  recurrence,  and  that  the  patient 
was  in  very  good  health.  In  a  less  marked  case  of  intra-tubal  pai)illoma 
in  his  practice  the  result  had  proved  equally  satisfactory. 

The  remarkable  symptom  which  was  so  prominent  in  this  case  is 
evidently  identical  with  the  '•'  hydrops  tubae  profluens  "  of  old  writers, 
though  watery  discharge  may  occur  in  simple  hydrosalpinx.  Indeed, 
case  1  Avas  an  instance  of  the  same  phenomenon,  save  that  the  fluid 
discharged  itself  into  the  peritoneal  cavity  and  not  externally. 

Case  6  fortunately  came  under  the  observation  of  a  competent 
observer,  Mr.  Bland  Sutton,  who  was  also  the  operator.  The  patient 
had  been  subject  to  pelvic  pain  and  menorrhagia  for  some  time.  "The 
right  tube  was  enlarged  to  the  size  of  a  finger ;  the  ostium  was  open, 
the  walls  greatly  thickened,  and  its  interior  stuffed  with  adenomatous 
masses  in  structure  resembling  those  found  in  Doran's  specimen  (Xo.  1 ). 
There  was  no  hydroperitoneum  or  watery  discharges  from  the  vagina." 
Thus  Sutton's  valuable  report  shoAvs  that  in  papilloma  of  the  tube 
with  patulous  ostium  peritoneal  effusion  is  not  always  present.  On  the 
strength  of  his  evidence  I  have  refrained  from  generalising  on  this  rare 
disease ;  it  shows,  at  least,  that  one  important  clinical  symptom  was 
absent  in  1  out  of  3  similar  cases  (Nos.  1,  4,  and  6).  The  left  tube  in 
case  6  was  strangulated  by  an  adhesion  between  the  ovary  and  intestine; 
it  did  not  bear  papillomas.  The  patient,  Mr.  Sutton  kindly  informs  me, 
was  living  nearly  four  years  after  the  operation. 

Since  the  above  notes  were  prepared,  Godart  (19a)  has  described  a 
case  where  abdominal  section  was  performed  for  symptoms  of  pelvic 
inflammation  in  a  Avoman  aged  32.  In  a  dilatation,  as  big  as  a  Avalnut, 
in  one  tube,  there  Avas  a  papillomatous  mass  consisting  of  hypertrophied 
plicae.  He  looked  upon  it  as  a  purelA'  inflammatory  condition,  not  a 
new  growth,  a  distinction  Avhich  I  have  already  discussed. 

Treat  incut. — The  clinical  and  pathological  evidence  above  given  in- 
dicates but  one  line  of  treatment,  removal  of  the  diseased  tube.  The 
ovary  must  be  removed  Avith  it.  The  ligature  should  be  tied  close  to 
the  uterus,  and  if  papillomatous  growths  are  seen  on  the  exposed  mucosa 
of  the  stump  they  should  be  destroyed  Avith  the  thermo-cautery.  Prog- 
nosis must  be  guarded  even  after  a  successful  operation.  Ko  doiibt 
the  after  historv  in  case  1  is  most  encouraging,  but  it  Avill  be  seen  that 


8i2  SYSTEM   OF  GYNECOLOGY 

the  distinction  between  papilloma  and  cancer  is  not  by  any  means 
easy. 

Cancer  of  the  Fallopian  Tubes.  —  There  can  be  no  doubt  that  the 
Fallopian  tube  may  be  the  seat  of  primary  cancer.  Until  a  few  years 
ago  it  was  asserted  in  text-books  that  authors  were  agreed  that  cancer 
of  the  tube  is  always  secondary.  Since  attention  was  first  turned  to  the 
subject,  cases  of  alleged  primary  cancer,  not  always  indisputable,  have 
been  published  from  time  to  time  by  clinical  and  pathological  observers. 

Those  who  speak  of  tubal  cancer  as  always  "  secondary  "  are  further 
incorrect  in  that  they  usually  mean  to  imply  simple  extension  of  malig- 
nant disease  from  the  uterus  or  ovary.  A  good  instance  of  this  extension 
of  cancer  from  the  uterus  is  described  and  figured  in  Sir  John  Williams' 
Harveian  Lectures.  Drs.  Ballantyne  and  Williams  record  an  interesting 
case  of  cancer  of  the  tube,  which  they  are  inclined  to  consider  as  "  sec- 
ondary," in  the  true  pathological  signification  of  the  term.  Scanzoni's 
case  is  sometimes  reported  as  primary  tubal  cancer.  I  believe  that  it 
began  in  the  ovary,  as  that  organ  was  "  of  the  size  of  a  fist,"  whilst  the 
tube  was  only  ''of  the  thickness  of  man's  thumb."  This  proportion  is 
reversed  in  No.  2  in  the  appended  tables.  Scanzoni  observes  that  his 
case  proves  that  cancer  of  the  tubes  does  not  always  arise  from  the 
contiguity  of  those  organs  to  diseased  neighbouring  structures.  It  seems 
likely  that  the  tube  was  affected  with  true  secondary  cancer. 

In  cancer  of  the  ovaries  the  tubes,  as  a  rule,  are  not  involved  till  very 
late,  if  at  all.  I  have  repeatedly  seen  the  tube  quite  healthy  when  the 
corresponding  ovary  had  become  a  large  sarcomatous  or  carcinomatous 
tumour.  Schroeder  and  Ballantyne  and  Williams  note  this  clinical  fact. 
Sanger  (41,  Fig.  53)  describes  a  case  of  cancer  of  the  ovaries  extending 
to  the  tubes,  which  remained  quite  small  though  distinctly  infected. 
Extension  of  cancer  from  the  uterus  to  the  tube  is  not  common. 

Since  Dr.  Orthmann  described  Dr.  Martin's  case  (No.  1)  over  a  dozen 
instances  of  primary  cancer  of  the  tube  have  been  described.^  Two  forms 
may  be  distinguished :  in  the  first,  carcinoma  develops  in  the  mucous 
membrane  of  a  normally  formed  tube ;  in  the  second  it  develops  in  a 
tube  which  is  malformed,  bearing  a  cyst  (not  connected  with  the  ovary) 
into  which  the  ostium  opens.     The  cyst  wall  becomes  infected. 

1.  Primary  Cancer  of  a  normally  developed  Fallo^nan  Tube.  —  In  May 
1888, 1  stated  at  a  meeting  of  the  Pathological  Society  "  that  malignant 
disease  of  the  tube  may  result  from  a  degeneration  of  papillomata  of  the 
tubal  mucous  membrane."  This  remark  was  in  reference  to  the  specimen 
(case  No.  2)  which  I  then  exhibited.  Since  that  date  this  opinion  has 
been  confirmed  by  othcu-  writers  who  have  examined  other  specimens. 
I  have  already  shown  that  papilloma  tends  to  degenerate  into  carcinoma 
(p.  80G) ;  I  may  now  add  that  it  is  not  easy  to  distinguish  papilloma  of 

'  I)r.  Rf;naiul  of  Manchester,  in  an  Atlas  of  uiipiihlislH^d  patliolofjical  drawings,  now  in 
the  Lihraryof  11ieMii8(!urnof  theColl(!^(!of  SiirfiBotiH,  fifi;iir(!sas))e<^iinenof  "  medullary  can- 
cer of  tlic  riylit  and  left  oviduct,  alsoof  I'lj^lit,  and  l(ift  ovaries."  The  date  is  November  1847. 
As  far  us  can  Ijc  judf^ed  from  adrawin;^  the  disease  appears  to  have  originated  in  the  tubes 


DISEASES   OF  THE  FALLOPIAN   TUBES  813 

the  tube  from  carcinoma.  Landau  and  Rheinstein  (Xo.  o)  discuss  the 
histology  of  those  new  growths  very  carefully.  The  column  "  Character 
of  the  Tumour  "  in  the  tables  shows  how  frequently  the  supposed  cancer 
was  papillomatous,  at  least  in  appearance  (ISTos.  1,  3,  4,  6,  7,  8,  9,  10,  12, 
13,  14,  15).  The  distinction  between  "villous"  and  papillomatous" 
must  remain  doubtful.  The  actual  origin  of  these  papillomas  from 
papillae,  described  at  page  804,  must  be  carefully  borne  in  mind  when  any 
case  of  cancer  is  considered.  I  have  given  reasons  for  believing  that 
the  morbid  papillae  develop  on  the  mucosa  of  tubes  subject  to  chronic 
inflammation.^  Hence,  in  the  tubes,  cancer  seems  to  be  a  distant  sequel 
of  inflammation.  The  "  Chief  Symptoms  "  column  in  the  Tables  of 
Papilloma  and  Carcinoma  tends  to  confirm  this  theory. 

The  appended  tables  are  based  on  a  more  limited  compilation  wliich 
I  prepared  for  my  second  report  of  case  2.  It  has  been  extended  b}"  Dr. 
Fearn  and  by  Sanger  and  Barth.  I  here  add  fresh  cases  and  additional 
information  -  respecting  recurrence  and  other  matters  on  cases  alread}^ 
reported.  For  such  information  I  must  thank  the  gentlemen  after  whose 
names,  in  the  "  Reporter  and  Reference  "  column,  I  have  added  the 
words  "  private  correspondence."  These  words  will  serve  to  explain 
how  certain  facts  not  in  the  original  printed  records  came  to  be  inserted 
in  the  tables. 

In  case  1  there  is  a  long  history  of  pelvic  inflammation,  following  an 
attack  of  typhoid  fever  one  year  and  a  half  before  operation ;  but  the 
inflammation  may  have  arisen  from  abortion  a  little  previous  to  the 
fever.  The  mucous  membrane  of  the  tube  was  covered  with  soft 
papillomatous  growths  filling  the  lumen  of  the  abdominal  end,  where 
they  were  numerous.  Each  growth  consisted  of  a  stroma  or  connective 
tissue,  including  numerous  nests  of  epithelial  cells.  Here  and  there 
involutions  of  epithelium  were  detected  passing  into  the  stroma.'' 

I  was  present  at  the  operation  upon  No.  2,  and  made  a  minute 
examination  of  the  diseased  tube.  I  was  also  enabled  to  inspect  the 
pelvic  viscera  after  the  patient's  death  from  recurrence.  The  specimen 
is  preserved  in  the  Museum  of  the  Royal  College  of  Surgeons,  No. 
4584  D. 

At  the  operation  the  infected  ovary,  much  smaller  than  tlie  diseased 
•tube,  was  found  strongly  adherent  to  adjacent  structures  ;  the  examina- 
tion of  the  pelvic  viscera  ten  months  later  showed  that  none  or  very 
little  of  the  ovary  was  left  behind,  as  the  operator  feared  at  the  time. 
The  uterus  was  quite  healthy.  The  cancerous  tube  measured  five  inches 
in  length  when  collapsed.  It  contained  several  drachms  of  ill-smelling, 
bloody  serum  with  minute  solid  fragments.  This  fluid  closely  resembled 
the  vaginal  discharge  which  Dr.  Amand  Routh,  who  attended  the  case 

1  See  especially  the  observations  No.  .3  in  Tables  of  Papillonia  of  the  Tube. 

-  Thus  in  Siinger  and  Karth's  tables  there  is  no  note  under  Kaltoiibach's  case  (Xo.  3 
iu  my  tables)  that  recurrence  took  place. 

3  See  the  fine  microscopio  drawincjs  in  Orthniann's  original  paper  (reference,  No.  1 
iu  tables) . 


Si4 


SYSTEM   OF  GYNAECOLOGY 


before  operation,  had  already  observed.  Almost  the  entire  mucous 
membrane  was  covered  with  a  soft  and  highly  villous  growth  of  a  bright 
red  colour. when  fresh.  No  trace  of  ostium  or  fimbriae  could  be  found. 
The  ovary  was  almost  spherical,  and  measured  in  its  long  diameter  about 
one  inch  and  three-quarters.     No  normal  ovariaii  tissue  remained. 

The  microscope  showed  that  the  new  growth  in  the  tube  consisted  of 
large  polymorphous  cells.  They  formed  clusters  bounded  by  trabeculse, 
in   which   the   connective-tissue    cells   were   undergoing    proliferation 


Fig.  208.  —  Primary  cancer  of  Fallopian  tnhe.  Case  2.  a.  Uterine  end  of  tTibe  divided  at  the  oporation. 
A  black  bristle  has  been  passed  throu^'h  it  alon<?  the  channel  of  the  tube,  h,  rortion  of  the  tube 
near  the  uterine  end  free  from  growths;  c,  c,  <•,  masses  of  cancerous  growth  springing  from  the 
inner  surface  of  the  tube  ;  d,  new  growth  invading  the  muscular  coat,  which  is  elsewliere  mostly 
free  from  disease  ;  /,  ovary  converted  into  a  mass  of  tumour  substance  ;  (/,  cut  surface  of  broad 
ligament,  which  is  infiltrated  with  new  growth. 


TFig.  209).  In  the  deeper  parts  I  noted  some  well-formed  tubules  lined 
with  perfect  columnar  ciliated  epithelium  and  surrounded  by  a  wide  area 
of  large  cells.  The  precise  significance  of  these  tubules  is  not  at  first 
sight  clear.  Senger,  in  his  case  of  sarcoma  (No.  1,  Sarcoma  Tables), 
detected  tubes  lined  with  cylindrical  epithelium  in  the  tumour  substance, 
and  traced  them,  as  Von  Recklinghausen  would  do,  to  the  parovarium. 
Sanger  in  commenting  on  Senger's  case,  insists  that  such  "  tubes  are 
not  glands,  as  Henger  maintains,  but  simply  outrunners  from  normal  plicse 
or  from  pajjillomatous  growths.  E})ci't]i  and  K!tlt(',n])ach  have  already 
noted  these  false  tubes.  1  [(nice  these  "  tul)ules  "  a,re  y)ossibly  homologous 
to  the  "  cysts  "  lined  with  epithelium,  on  which  I  dwelt  in  my  observations 


b  — 


—  a 


F"-- 2ii0.  —  Priiiian- oanoer  of  Fnllopian  tube. 
I.   Section   of  oanccrous   growth  inva.linfr  tho  ^v■M  of  tl>e  ti.be. i  i„eh  objective),     a,  a,  Larjre  nolv 

cP'l'Tnlf^  =    ;-  '?'";*  "  ."  •■•=>'"^<^>'>".  '-"<lin.'  tho  j:ro„p  o.' cells,  shelving  small  eel  uZJSil 
TT     -?'  ^'  f '  "  "-'Cle-cells  indu-atincr  remains^  of  the  muscular  coat  of  tube.  " 

Tubule-hke  structure  „   seen  in  cancerous  (.-rowth  (see  text).     It  is  lined  with  cvlindrical  ciliate.I 

prolonged  outwards  into  the  stroma  at  c,  c.     Farther  on,  at  rf,  are  larger  cells.  ' 

815 


8i6  SYSTEM  OF  GYNECOLOGY 

on  salpingitis.  Possibly  again,  the  tubules  may  be  Wolffian  relics,  such 
as  Von  Eeeklinghausen  has  recently  described.  Fabricius  (17a)  believes 
in  involutions  and  outrunners  from  the  tubal  mucosa.  He  has  traced 
them  to  the  serous  coat.  In  short,  there  are  several  probable  explanations 
of  the  origin  of  the  tubules  in  Fig.  209,  but  it  is  not  clear  which  is  correct. 

The  ovary  seemed  to  be  made  up  of  the  collections  of  large  cells 
bounded  by  trabecules  as  in  the  tubal  growth.  The  disease  seems 
clearly  to  have  originated  in  the  tube,  where  it  was  more  advanced  than 
in  the  ovary.  The  clinical  symptoms  before  operation  all  indicated  not 
ovarian  tumoiir,  but  tubal  disease. 

The  patient  died  from  recurrence  nearly  eleven  months  after  the 
operation.  Dr.  Amand  Routh  kindly  brought  me  the  pelvic  viscera  for 
inspection,  and  I  published  my  report.  The  surface  of  the  cervical  ca- 
nal and  the  endometrium  bore  numerous  slightly  elevated  white  spots 
representing  secondary  deposit;  otherwise  the  uterus,  though  rather 
bulky,  was  normal.  A  spherical  mass  of  cancer,  not  one  inch  in  diameter, 
lay  to  the  right  of  the  cervix  in  Douglas'  pouch,  in  a  situation  corre- 
sponding to  the  point  of  adhesion  of  the  diseased  ovary. 

No.  3  shows  how  difficult  it  is  to  distinguish  a  malignant  papillary 
carcinoma  from  an  innocent  papilloma  of  the  tube.  I  have  shown  how 
iSTo.  1,  in  the  Tables  of  Papilloma,  looked  very  malignant,  yet  proved 
innocent.  The  present  case  was  described  by  Professor  Kaltenbach  in 
a  society  report  as  "  primary  bilateral  tubal  cancer."  Shortly  afterwards 
I  published  the  sequel  or  post-mortem  report  of  case  2.  I  stated  that 
Kaltenbach's  case  appeared  "  to  represent  simultaneous  cancerous  de- 
generation of  papillomatous  tubes."  A  few  months  later  the  deceased 
professor,  in  conjunction  with  Dr.  Eberth,  issued  a  complete  report  of 
the  pathological  appearances  of  the  tubes.  They  traced  the  growth 
from  its  beginning  as  papillae  springing  from  the  mucosa,  as  I  did,  in  the 
case  of  No.  3,  Tables  of  Papilloma,  at  the  very  same  time.  These 
"  independent  researches"  are  discussed  at  page  804.  They  went  farther, 
and  declared  that  they  could  in  no  part  of  the  growth  detect  any  invasion 
of  the  stroma  of  the  papillae  by  the  epithelium,  that  is  to  say,  any  true 
cancerous  process. 

CFnfortunately  the  disease  recurred  after  this  careful  report  was 
published.  In  reply  to  inquiries.  Professor  von  Herff,  Kaltenbach's 
successor,  informed  me  last  year  that  the  patient  was  readmitted  into 
hospital,  and  extensive  recurrence  was  detected.  "  She  could  hardly  have 
lived  much  longer,  but  I  could  not  obtain  further  information."  (See 
Tables,  No.  3.)  Either  Kaltenbach  overlooked  an  area  of  cancerous 
degeneration,  and  thus  failed  to  include  it  in  his  microscopic  sections, 
or  more  probably,  some  papiHomatous  tissue,  left  behind  after  operation, 
l)ecame  malignant. 

Sanger  and  Barth  observe  in  their  work  that  Eberth  and  Kalten- 
bach considered  that  the  tumour  in  question  was  malignant,  and  that 
"Doran  classes  it  without  further  discussion  under  Cancer";  at  pages 
265,  2GG  they  still  write  doubtfully  as  to  the  malignancy  of  the  same 


DISEASES    OF   THE    FALLOPIAN   TUBES  817 

tumour.  But  in  their  tables,  under  the  heading  "  Result  of  Operation," 
I  find,  "  Still  quite  well  three-quarters  of  a  year  later."  It  is  fortunate 
that  I  applied  to  Professor  von  Herff ;  the  consequence  is  that  I  have 
added,  under  the  same  heading,  "  Eecurrence  within  eighteen  months,"  — 
most  important  evidence  in  relation  to  the  malignancy  question. 

On  the  other  hand.  No.  4  was  described  as  "  a  case  of  carcinoma  of 
the  tube,"  at  a  meeting  of  the  Berlin  Obstetrical  Society,  l-ith  December 
1888.  Professor  Veit  removed  it  in  September  of  that  year.  There 
was  pyosalpinx  ;  the  inner  surface  of  the  tube  was  studded  with  abundant 
small  growths,  and  microscopic  examination  of  the  latter  plainly  demon- 
strated carcinoma.  Professor  Veit,  however,  informs  me  that  the  patient 
was  free  from  recurrence  and  in  excellent  health  seven  years  later. 
Hence  either  the  papillomatous  growths  w^ere  malignant  in  appearance 
only,  or  else  the  distinguished  professor  extirpated  a  cancer  very 
thoroughly. 

No.  5  is  the  subject  of  an  excellent  monograph,  where  the  opinions 
of  Kaltenbach  and  myself  on  papilloma  are  impartially  considered. 
Landau  and  Rheinstein,  the  authors,  are,  however,  too  sanguine  when 
they  infer  that  papillomatous  growths  in  the  tube  are  "not  to  be 
reckoned  amongst  malignant  tumours."  They  rely  on  an  observation 
of  their  own  and  on  the  history  of  my  own  cases  (Nos.  1  and  3,  Tables 
of  Papilloma).  No.  3  in  the  Cancer  Table,  however,  proves  that  a 
papilloma  of  the  tube  is  always  suspicious.  Landau's  case  appeared  to 
be  an  instance  of  medullary  cancer ;  he  gives  a  good  drawing  of  a  section. 
As  in  case  2  the  disease  was  advanced;  it  most  likely  represented  a 
growth  originally  papillomatous.  Recurrence  was  less  rapid  than  miglit 
have  been  expected  in  so  clearly  malignant  a  growth. 

No.  6  was  carefully  examined  by  Professor  Zweifel.  At  first  sight 
sections  viewed  under  the  microscope  seemed  to  indicate  sarcoma ;  but 
the  cells  with  very  large  nuclei,  which  lay  in  groups  in  alveoli  amidst  the 
stroma,  were  traced  to  the  epithelium  of  the  tube.  Zweifel  comments  on 
the  great  resemblance  between  the  new  growth  in  his  case  and  that 
which  I  described  as  No.  1  in  the  Tables  of  Papilloma.  The  latter  would 
have  had  the  fate  of  the  former,  we  may  fairly  assume,  had  operation 
been  delayed.  Zweifel,  less  fortunate  than  Spencer  AVells,  had  the  dis- 
advantage of  operating  when  the  disease  w^as  advanced  and  bilateral. 

No.  7  has  frequently  been  quoted  from  second-hand  sources,  the 
original  record  being  published  in  a  Scandinavian  medical  serial.  The 
authors  give  excellent  reasons  for  believing  that  the  morbid  growth  was 
a  papillomatous  cancer ;  they  maintain  that  the  infection  of  the  right 
ovary  was  secondary,  quoting  my  observations  concerning  infection  of 
the  tube  in  primary  ovarian  cancer  (see  p.  812). 

Professor  Sanger  removed  a  papillary  cancer  of  the  right  tube  "  as 
big  as  a  goose's  egg"  (No.  8).  The  patient  was  fortj^-five;  and,  as  in 
Thornton's  case,  there  was  a  history  of  raenorrhagia.  The  uterus  was 
dilated  and  explored,  but  found  to  be  free  from  any  now  growth.  Shortly 
afterwards  abdominal  section  was  performed,  and  the  right  tube  was  found 

3g 


8i8  SYSTEM  OF  GYNMCOLOGY 

occluded  at  its  abdominal  end  and  cancerous ;  but  between  the  infected 
part  and  the  uterus  was  an  inch  and  a  half  of  tube  free  from  cancer,  but 
subject  to  chronic  inflammation.  The  growth  seems  to  have  advanced 
slowh- ;  and  Professor  Sanger  considered  it  to  be  a  papilloma  which  had 
undergone  malignant  degeneration.  The  patient  was  in  good  health  and 
free  from  recurrence  seven  months  after  the  operation.  The  operator 
has  published  a  complete  report  of  this  case,  with  good  microscopic 
drawings.  His  opinions  on  the  papillary  origin  of  the  growth  are  in 
accordance  with  my  own  ;  and  in  this  case  there  was  a  history  of  old 
inflammation,  which  may  indicate  that  the  papilloma  was  a  product  of 
inflammation.  As  for  the  appearances  of  the  malignant  changes  in 
the  growth  in  case  8,  he  admits  that  they  reminded  him  strongly  of 
malignant  adenoma  of  the  uterus  and  papillary  adeno-carcinoma  of  the 
ovary  (toe.  cit.  p.  257) ;  but  he  cannot  consider  that  the  growth  No.  8  is 
homologous  to  uterine  and  ovarian  tumours  of  the  varieties  just  noted, 
as  he  is  by  no  means  certain  that  gland-like  structures  are  to  be  found  in 
the  tube. 

No.  9  is  excellently  described  by  Dr.  Fearn.  His  microscopic  re- 
searches support  my  views  that  papilloma  of  the  tube  is  truly  papilloma- 
tous from  the  first ;  that  this  growth  tends  to  develop  in  tubes  subject 
to  chronic  inflammation,  and  that,  as  m  No.  9,  it  may  undergo  malignant 
degeneration.  According  to  his  drawing  of  the  diseased  tube,  it  looks 
very  like  that  in  No.  2  (see  Fig.  206).  Though  he  describes  the  growth  as 
'■heteroplastic  throughout,"  the  patient,  Professor  Leopold  informs  me, 
showed  no  sign  of  recurrence  a  year  and  seven  months  after  the  operation. 

In  No.  10  it  is  to  be  regretted  that  no  note  was  made  of  the 
condition  of  the  right  ovary.  The  sequel,  however,  showed  that  the 
ovary  could  not  have  been  cancerous,  as  the  patient,  MM.  Tuffier 
and  Hartmann  inform  me,  was  free  from  recurrence  a  year  after  the 
operation. 

Case  11  occurred  in  Dr.  Cullingworth's  practice,  and  has  been  fully 
described.  In  October  1S94  the  operator  and  Mr.  Shattock  kindly 
allowed  me  to  examine  the  specimen. 

The  tube  measured  a  little  under  three  inches.  It  was  shaped  like  a 
gherkin,  with  a  large  prominence  (Fig.  210,  a)  externally.  Its  walls 
were  very  thick  ;  the  lumen  wide  for  the  first  two  inches,  then  lost,  so 
that  it  was  uncertain  whether  it  went  into  the  prominence  a,  or  ended 
near  h.  No  trace  of  a  fimbriated  extremity  could  be  seen.  The  inner 
wall  was  very  irregular,  and  at  points  (c,  c)  there  seemed  to  be  a  smooth 
inemV^rane  over  the  new  growth  in  the  walls.  This  new  growth  was 
spongy  on  section,  exposing  irregular  cavities  ;  minute  papillary  growths 
sprouted  inside  these  cavities.  Mr.  Shattock  compared  this  intra-tubal 
cystic  growth  to  what  is  seen  in  duct-cancer  of  the  breast.  The  meso- 
salpinx was  opened  up,  so  that  the  tube  lay  on  the  ovary,  which  was 
converted  into  a  cyst.  On  the  surface  of  this  cyst  were  some  small 
papillary  masses  similar  to  the  growths  in  the  tul)es. 

Under  the  microscope  the  sponge-like    tissue;  showed  spaces  with 


DISEASES   OF   THE  FALLOPIAN   TUBES 


iig 


projections  of  the  character  of  villi.  Groups  of  cylindrical  epithelial 
processes  were  detected  in  the  connective  tissue  matrix.  These  processes 
acquired  a  lumen,  which  grew  larger  till  the  cystic  appearance  was 
developed.  Mr.  Shattock  lias  minutely  described  these  characters  else- 
where. It  is  clear  that  the  tubal  growths  and  the  secondary  deposits  on 
the  ovarian  cyst  were  carcinomatous. 

Warnek,  a  Russian  authority,  describes  No.  12,  the  details  of  which 
are  sufficiently  explained  in  the  tables.  The  pedicles  of  both  diseased 
tubes  were  twisted.  The  malignancy  of  the  growths  was  determined 
by  Dr.  Nikiforoff,  Professor  of  Pathological  Anatomy  in  the  University 
of  Moscow.  Two  features  of  particular  interest  are  to  be  noted  in 
jS'o.  12.    There  was  atubo-ovarian  cyst  on  the  right  side.    The  papilloma- 


FiG.  210.  — Dr.  Ciillingworth's  case  of  primary  cancer  of  the  tube.     It  i.s  seen  lying  on  the  surface  of 
the  cystic  ovary.     For  lettering  see  te.vt. 

tons  masses  in  the  left  tube  were  pedunculated.  These  facts  associate 
the  case  with  No.  3  in  the  papilloma  series,  where  tubo-ovarian  cyst  was 
in  course  of  development ;  though  the  cavities  of  the  tube  and  ovary, 
both  cystic,  did  not  as  yet  communicate.  In  that  case  some  of  the 
papillomas  were  pedunculated.  In  other  words,  No.  3  Papilloma  Tables 
seems  to  rein-esent  an  early  stage  of  the  condition  seen  in  Warnek's  case. 
No.  13  will  shortly  be  reported  in  full ;  it  is  said  to  be  a  genuine 
example  of  primarj-  cancer.  No.  14  is  a  case  where  tubo-ovarian  cyst 
seems  to  have  existed.  The  right  tube  was  dilated,  and  opened  into  a 
large  cyst  which  contained  over  17  pints  of  dirty  brown  fluid  with 
sloughy  shreds.  This  cyst,  let  it  be  remembered,  could  not  be  com- 
pletely removed,  and  the  limits  of  tube  and  ovary  do  not  seem  certain. 
It  may  be  homologous  to  Warnek's  case  (No.  12),  and  thus  represent  a 
malignant  degeneration  of  the  condition  seen  in  No.  3  Papilloma  Tables. 


820  SYSTEM  OF  GYN.-ECOLOGY 

On  the  other  hand,  the  cyst  into  which  the  tube  opened  may  have  been 
independent  of  the  ovary,  as  in  Essex  Wynter's  case  which  will  be 
described  under  a  special  heading. 

Xo.  15,-  which  is  published  in  full  in  Pean's  Avork,  issued  in  the 
summer  of  1895,  bears  a  certain  resemblance  to  No.  2.  There  Avas 
sanious  discharge  for  some  time.  A  special  feature  was  the  disappearance 
and  reappearance  of  the  hypogastric  tumour.  "  Hydrosalpinx  profluens  " 
was  diagnosed.  The  case,  in  fact,  seems  a  malignant  form  of  No.  5 
(Doleris)  in  the  Papilloma  Tables.  M.  Pean  is,  I  find,  very  sceptical 
about  the  primary  character  of  tubal  cancer.  I  have  already  shown,  how- 
ever, how  that  the  tube  is  subject  to  papilloma,  and  how  the  papilloma 
may  become  cancerous,  —  facts  favouring  the  probability  of  primary  can- 
cer of  the  tube.  Moreover,  Pean  seems  to  believe  in  case  15,  Avhere  there 
was  clearly  a  true  cancerous  degeneration  of  tubal  papilloma. 

A  few  more  cases  of  primary  cancer  of  the  normal  Fallopian  tube 
have  been  reported,  but  less  fully  than  those  already  described.  Dr. 
Smyly,  of  Dublin,  relates  that  "  I  operated  upon  one  case  of  cancer  of 
the  tube,  supposing  it  to  be  an  inflammatory  condition.  The  operation 
was  exceedingly  diflicult,  and  the  rectum  Avas  opened  in  tAVO  places. 
These  I  closed  by  suture ;  but  the  patient  died  of  collapse.  The  true 
nature  of  the  case  was  revealed  by  the  microscope."  Dr.  Smyly  informs 
me  that,  unfortunately,  the  report  of  the  case  has  been  lost.  At  the  time 
of  the  operation  he  had  no  idea  that  he  "was  dealing  with  a  case  of 
malignant  disease.  The  tissue  Avas  very  friable,  though  not  more  than 
in  many  inflammatory  cases.  The  uterus  appeared  normal  and  the  tube 
and  ovary  on  the  opposite  side  AA'ere  free  from  disease.  The  specimen 
was  examined  by  Dr.  Earl,  a  very  competent  pathologist  and  assistant 
to  the  Professor  of  Physiology  in  Dublin  University.  He  reported  it 
as  undoubtedly  cancer.  Had  I  suspected  this  I  should  certainly  have 
examined  the  uterus,  but,  imfortunately,  the  woman  was  buried  before 
I  received  his  report.  There  Avas  no  cancer  anywhere  else  so  far  as  I 
could  see  at  the  operation." 

Professor  Zweifel  recorded  a  second  case  of  primary  cancer  of  the 
tube  in  1894.  As  in  Dr.  Cullingworth's  case,  it  Avas  associated  with 
an  ovarian  cyst ;  and  the  diseased  part  corresponded  in  naked-eye  ap- 
pearances Avith  the  cancerous  tube  in  case  6.  Dr.  Westermark  sent  me 
the  folloAving  important  piece  of  information  in  January  1895 :  "  I  prom- 
ised, in  my  paper,  a  future  description  of  a  new  case  of  cancer  of  the 
tube,  but  at  the  last  research  this  case  showed  itself  to  be  a  cancroid 
developed  in  the  ovary  (probal)ly  arising  from  a  dermoid),  Avhich  had 
groAvn  into  the  tube.  In  July  last  I  operated  on  another  case  of  primary 
cancer  of  the  tube,  but  as  the  pathological  research  is  not  finished,  I  am 
unable  at  present  to  give  any  further  description."  Siinger,  in  his  tables, 
adds  the  name  of  Mischnoff,  but  all  that  is  said  of  the  case  is,  "  Not 
certain." 

2.  Primary  Cancer parf.ly  i.a  a,  Ci/st  connected  ivUh  fhr.  Oi^l.iimi.  —  A  second 
form  of  jjrimary  cancer  of  the  tube  has  been  noted  l)y  tw(j  observers,  and 


DISEASES   OF   THE   FALLOPIAN   TUBES  821' 

I  have  been  kindly  permitted  to  examine  the  first  case.  The  pathology- 
of  this  form  is  somewhat  obscure.  The  tube  is  malformed,  its  ostium 
opening  into  a  distinct  cyst.^  This  cyst  is  unconnected  with  the  ovary. 
Zedel  has  already  described  and  figured  the  anomaly  in  tubes  where 
there  Avas  no  suspicion  of  cancer. 

Essex  Wynter  and  lioutier  have  reported  these  remarkable,  though 
somewhat  obscure  cases.  I  am  much  indebted  to  Dr.  AVynter  and  Dr. 
Voelcker  for  assistance  in  a  thorough  investigation  of  the  case,  which 
is  briefly  reported  as  a  "  Card  Specimen  "in  the  transactions  of  the 
Pathological  Society. 

The  principal  features  are  recorded  in  the  tables  (Xo.  16).  The 
patient  had  menstruated  regularl}'  since  the  age  of  sixteen,  she  was  well- 
nourished,  but  complained  of  loss  of  strength,  having  been  stout.  The 
nature  of  the  disease  was  doubtful  during  life ;  her  memory  had  failed 
considerably.  Three  days  before  her  death  pain  began  in  the  hypo- 
gastric region,  and  there  had  been  vomiting  in  the  morning.  She 
became  delirious,  without  fever,  and  died  in  the  Middlesex  Hospital 
about  one  month  after  admission. 

There  were  caseous,  tubercular  deposits  at  the  apices  of  both  lungs. 
The  liver  was  small  and  fatty ;  the  kidneys  fibrocystic.  Other  organs 
were  normal,  and  there  was  no  new  growth  in  them  or  in  the  lymphatic 
glands.  There  was  no  ascites,  and  with  the  exception  of  a  few  intestinal 
adhesions  to  the  tumour,  the  abdominal  viscera  were  healthy.  A  cyst 
of  the  size  of  an  ostrich's  egg  was  attached  to  the  right  tube,  with  which 
it  was  continuous.  This  cyst  contained  8  oz.  of  brownish  fluid.  It  had 
ruptured  and  leaked ;  but,  in  Dr.  Wynter's  opinion,  not  till  after  death. 
There  was  no  sign  of  peritonitis. 

Such  is  the  report.  The  exact  cause  of  death  remains  obscure. 
The  absence  of  any  new  growth  beyond  the  limits  of  the  tube  and  its 
abnormal  cystic  appendage  remains  certain. 

I  examined  the  specimen  myself  in  October  1894.  The  appearances 
are  indicated  in  Fig.  211. 

The  right  tube  measured  4  inches  in  length.  The  corresponding 
ovary  (Fig.  211,  d),  1^-  inches  in  its  longest  measurement,  was  atrophied, 
elongated,  and  very  thin.  The  ovarian  ligament  was  abnormally  long. 
The  outer  end  of  the  ovary  tailed  off  on  to  the  surface  of  the  cyst,  from 
which  that  organ  was  otherwise  quite  distinct. 

The  first  inch  of  the  right  tube  was  relatively  narrow,  and  united  to 
the  elongated  ovarian  ligament  by  membranous  perimetritic  bands.  The 
second  inch  and  a  half  was  dilated  and  very  tortuous,  and  over  an  inch 
in  diameter  in  its  widest  part.  The  remaining  and  outermost  part  of 
the  tube  was  yet  more  dilated,  forming  a  spherical  cyst  over  an  inch  in 
diameter ;  in  its  wall  was  a  solid  deposit  over  a  quarter  of  an  inch  in 
thickness  (a).     This  outer  portion  communicated  by  an  opening  (h)  with 

1  Dr.  Martin's  case.  No.  1,  injvy  be  of  this  kitid  ;  the  ostium  of  the  caneoron.s  right  tube 
opened  into  a  cavily  full  of  pus.  As,  however,  tliere  was  suppuratiou  of  the  left  tube  and 
ovary,  tlie  cavity  most  likely  represeuled  aii  abscess. 


822 


SYSTEM  OF  GYNECOLOGY 


a  thiu-Tvalled  cyst  (c).  This  cyst  "^'as  quite  free  from  the  bladder,  and 
measm-ed  six  inches  in  diameter,  before  removal  at  the  necropsy ;  the 
anterior  part  had  burrowed  under  and  lifted  up  the  anterior  fold  of 
the  corresiX)nding  broad  ligament,  raising  the  serous  coat  of  the  uterus 
and  the  innermost  part  of  the  anterior  fold  of  the  left  broad  ligament. 
These  relations  are  not  indicated  in  Fig.  211,  which  was  taken  after  the 
peritoneum  had  been  displaced  during  dissection.  The  interior  of  the 
cyst  contained,  in  parts,  a  thick  deposit  which  appeared  encephaloid  in 
character. 

The  left  appendages  were  free  from  the  cyst.     The  tube  (e)  was  four 


Fig.  211.  —Dr.  Essex  Wynter's  case  of  cancer  of  the  tube.  The  uterine  cavity  (g)  has  been  laid  open. 
The  uterus  was  closely  adherent  to  the  cyst  (c),  but  did  not  communicate  with  its  cavity.  The 
rent  in  the  riffht  mesosalpinx  was  made  after  death.     The  view  is  anterior. 

inches  long,  the  iiifundiljulum  somewhat  dilated,  the  ostium  open.  The 
left  ovary  (/),  hardly  an  inch  long,  was  atropliied ;  the  ovarian  liga- 
jnent,  very  thick,  measured  an  inch  and  a  half. 

I  examined  with  ])r.  Voolcker  some  microscopical  sections  taken 
from  the  deposit  in  the  dilated  extremity  of  the  right  tul:)e.  The  stroma 
was  scanty  and  formed  wide  alveoli  containing  cubical  epithelium.  In 
parts  these  cells  were  collected  in  great  masses,  as  in  enceplialoid  cancer. 

All  evidence  seems  to  indicate  that  the  tube  was  the  primary  seat 
of  cancer,  the  disease  extending  to  the  abnormal  cyst  connected  with 
the  ostium.  No.  17,  M.  Koutier's  case,  resembled  Wynter's  in  many 
resxjects.     On  llie  liigh  authority  of  I'rofessor  Coniil,  the  growth  was 


DISEASES   OF   THE  FALLOPIAN  TUBES  823 

pronounced  to  be  "primary  epithelioma  of  the  tube."  Cornil  further 
considered  that  the  cyst  was  connected  with  the  tube,  and  was  not 
ovarian;  we  must  not  forget,  however,  that  the  corresponding  ovary 
could  not  be  found  at  the  operation.  Hence  the  cancer  may  have 
developed  in  a  true  tubo-ovarian  cyst.  Eighteen  months  before  the 
operation  sharp  pain  was  felt  in  the  left  iliac  region,  suddenly  "an 
enormous  quantity  of  lemon-coloured  fluid "  escaped  from  the  vagina. 
The  joain  lessened  and  the  tumour  became  at  once  much  smaller.  This 
escape  of  fluid  reminds  us  of  case  5  in  the  papilloma  series,  and  case 
15  in  the  Tables  of  Cancer.  The  etiology  is  quite  different,  but  the 
pathology  may  be  similar,  the  discharge  coming  from  papillomas  which 
ultimately  became  cancerous. 

General  Considerations  on  Cancer  of  the  Tube.  —  The  above  records 
amply  prove  that  cancer  of  the  tube  is  not  an  unknown  disease,  and  that 
it  may  certainly  be  primary.  ISTo  doubt  some  of  the  reporters  of  the 
sixteen  cases  which  are  included  in  the  Cancer  Tables  may  have  been 
mistaken.  A  primary  seat  of  malignant  disease,  more  or  less  distant 
from  the  tube,  may  have  been  overlooked.  The  tumour  may  in  one  or 
more  cases  have  been  sarcomatous,  not  cancerous.  In  one  or  more  cases 
an  innocent  papilloma  may  have  been  recorded  as  malignant.  Never- 
theless the  majority  of  the  cases  were  cancerous.  The  cancer  in  nearl}- 
every  tube  assumed  a  villous  or  papillomatous  appearance ;  the  exceptions 
are  doubtful,  as  the  disease  may  have  lost  a  papillomatous  character 
Avhich  it  originally  possessed.  The  origin  of  papilloma  may  usually  be 
traced  to  inflammatory  changes.  Hence  cancer  is  a  remote  result  of 
salpingitis  ;  or  perhaps  it  is  safer  to  say,  cancer  is  specially  apt  to  attack 
tubes  long  subject  to  inflammation. 

Clinically,  at  least,  the  early  history  of  tubal  cancer  nearly  always 
suggests  tubal  inflammation.  The  disease  is  unknown  in  youth.  Out  of 
the  seventeen  cases  in  the  Cancer  Tables  only  one  was  in  a  patient  so 
young  as  thirty-six;  and  in  this  instance  (Xo.  4)  the  after  history  indicated 
a  very  low  degree  of  malignancy.  Another  patient  was  forty -three.  All 
the  remaining  fifteen  patients  had  passed  their  forty-fifth  year. 

When  a  patient  Avho  has  reached  her  forty-fifth  year,  and  has  been 
subject  to  pelvic  inflammation,  shows  a  sudden  or  steady  aggravation  of 
subjective  and  objective  symptoms,  cancer  may  be  suspected.  A  Avatery 
or  especially  a  sanious  discharge  in  such  a  case  greatly  increases  the 
probability  of  malignancy. 

Treatment. — If,  as  has  been  shown,  removal  of  the  tube  is  necessary  in 
papilloma,  it  is  all  the  more  urgent  in  cancer.  Out  of  the  seventeen 
cases  in  the  tables,  sixteen  underwent  operation;  two  died  of  the  direct 
eftects  of  the  operation;  five  lived  over  one  year ;  four  died  within  a  3'ear ; 
whilst  in  five  the  after  history  is  incomplete — one  (Xo.  14)  being  convales- 
cent when  reported ;  one  (No.  13)  died  of  "  marasmus  "  at  an  uncertain 
date ;  one  (No.  15)  was  in  good  health  eight  months  later,  but  the  tumour 
had  recurred;  one  (No.  8)  was  still  alive  and  well  seven  months  after  opera- 
tion, whilst  the  fifth  (No.  1~)  never  reported  herself  after  convalescence. 


824  SYSTEM   OF  GYNAECOLOGY 

For  cancer  the  above  record  is  by  no  means  gloomy.  Even  wlien 
recurrence  Avas  comparatively  rapid  the  patients  seem  to  have  enjoyed  a 
few  months  of  comfort.  This  was  certainly  the  case  in  No.  2,  which  was 
under  my  own  observation.-^ 

Sarcoma  of  the  Fallopian  Tube.  —  In  primary  sarcoma  of  the  ovary,  a 
well-recognised  and  not  very  rare  disease,  the  tube  is  seldom  implicated. 
I  have  examined  enormous  sarcomas  of  the  ovary  where  the  tube  re- 
mained intact.  On  the  other  hand,  in  a  few  cases  I  have  seen  sarcoma- 
tous nodules  scattered  over  the  peritoneal  covering  of  the  tube.  The 
new  growth  more  frequently  passes  from  the  ovary  to  the  omentum,  and 
to  the  serous  investment  of  the  intestines,  uterus,  and  abdominal  walls. 

Few  can  deny  that  in  all  or  nearly  all  the  cases  of  alleged  primary 
cancer  of  the  tube  the  new  growths  were  carcinoma,  at  any  rate,  if 
not  primary.  Thoughtful  observers  have  expressed  doubts  whether  the 
recorded  cases  of  primary  sarcoma  of  the  tube  do  not  demand  a  different 
interpretation.  The  growths,  they  believe,  are  not  evidently  sarcoma 
or  even  true  neoplasms.  The  close  relations  of  papilloma  of  the  tube  to 
carcinoma,  and  the  tendency  of  the  former  to  degenerate  into  the  latter, 
have  already  been  noted.  When  the  stroma  of  a  papilloma  becomes 
abundant  it  may  possibly  undergo  sarcomatous  degeneration.  Some  of 
the  cases  in  the  tables  may  represent  this  change,  which  is  certainly  rarer 
than  cancerous  degeneration. 

Much  confusion  exists  in  relation  to  the  first  recorded  case,  as  the 
name  of  the  original  observer  is  Dr.  Senger,  which  is  often  misspelt 
"  Sanger,"  whilst  another  case  has  been  reported  by  Professor  Sanger 
himself.  In  this  case  (ISTo.  1,  Sarcoma  Tables)  papillomatovis  masses,  con- 
sisting of  small-celled,  round-celled  sarcomatous  tissue  were  found  growing 
from  the  tubal  mucous  membrane,  chiefly  in  two  oval  dilatations  of  the 
tube.  In  one  of  these  dilatations  there  was  a  polypoid  growth  contain- 
ing collections  of  tubules  lined  with  cylindrical  epithelium,  and  surrounded 
partly  by  true  sarcomatous  tissue,  partly  by  new  connective  tissue  rich  in 
nuclei.  Dr.  Senger  believes  that  these  tubules  were  derived  from  the 
parovarium ;  an  opinion  in  accordance  with  Von  Recklinghausen's  new 
hypothesis  quoted  above  (p.  806).  The  tubules  suggest  the  appearances 
which  I  detected  in  the  tube  from  case  2,  Cancer  Tables  —  an  instance 
of  cancer,  not  sarcoma,  whatever  the  tubules  may  have  been.  I  find  that 
Sanger  and  Barth  are  of  the  same  opinion.  Dr.  Coe  of  New  York  gives 
a  different  interpretation  to  this  morbid  appearance.  He  believes  that 
the  whole  growth  was  no  neoplasm,  but  chronic  inflammatory  deposit. 
Ife  has  observed  a  similar  condition  in  many  tubes  removed  for  chronic 
inflammatory  disease.  The  tubules  were,  he  considers,  simply  gland-like 
depressions  in  the  mucous  membrane  developed  by  the  folding-in  of  the 
hy  pertrophied  mucosa.  I  noted  this  condition  in  my  description  of  No.  2 
(Cancer  Tables),  but  observed  that  it  was  also  seen  in  papilloma.  The 
history  of  the  case  may  seem  to  favour  Dr.  Coe's  view  that  the  tube  was 

1 1  add  in  the  Cancer  Tables  two  eases  (15a  and  17a)  of  considerable  interest,  published 
since  the  above  lines  were  written. 


DISEASES   OF   THE  FALLOPIAN   TUBES  825 

the  seat,  not  of  a  tumour,  but  of  old  and  quiescent  inflammatory  disease. 
Dr.  Coe,  however,  must  not  overlook  the  fact  that  a  similar  history  is 
the  rule  in  cases  of  tubal  cancer.  The  presence  of  a  secondary  deposit 
in  Douglas'  pouch  makes  me  incline  rather  to  the  theory  that  the  morbid 
deposits  were  new  growths.  Sanger  (who  also  dwells  on  the  secondary 
deposit)  considers  that  Senger's  case  pathologically  resembled  his  own 
(No.  4,  Sarcoma  Tables). 

In  case  2  there  Avas  a  blood-cyst  as  big  as  an  apple  "between  the 
sacrum  and  right  ovary,  adjacent  to  a  tumour  of  the  size  of  a  walnut " 
developed  in  the  abdominal  portion  of  the  right  tube,  the  lumen  of  which 
was  pervious.  This  tumour,  on  the  high  authority  of  Professor  Landau, 
was  a  small-celled,  spindle-celled  sarcoma.  No  relation  between  the 
blood-cyst  and  the  sarcoma  is  suggested,'  nor  any  reference  made  to  tubal 
pregnancy ;  the  latter  subject  will  be  discussed  in  respect  to  Dr.  Charles 
Dixon-Jones'  cases. 

Case  3  must  remain  doubtful.  Dr.  Janvrin's  original  report  is 
excellent.  Unfortunately,  as  in  case  2,  the  patient  died  a  few  days 
after  the  operation,  so  that  we  cannot  tell  Avhether  recurrence  could 
have  occurred  had  either  patient  recovered.  The  pathologist,  Dr. 
Porter,  does  not  speak  very  decidedly  about  Janvrin's  tumour.  ••'  The 
general  histological  construction  of  this  newly  developed  tissue  would 
argue  against  its  being  classed  as  an  inflammatory  growth,  but  would 
place  it  among  the  mixed  connective-tissue  growths.  Owiug  to  the  large 
variety  of  histological  elements  found,  it  is  impossible  to  give  it  any 
single  name  which  will  in  any  adequate  manner  express  the  condition. 
It  may  well  be  classed  under  one  of  two  headings,  either  as  a  composite 
tibro-sarcoma,  or  a  composite  rayxo-sarcoma,  the  latter  being  the  more 
accurate  of  the  two."  The  photogravure  appended  to  Janvrin's  paper 
and  the  clinical  report  alike  suggest  that  the  tube  was  the  seat  of  chronic 
inflammatory  changes.  Such  changes,  on  the  other  hand,  are  sometimes 
followed  by  malignant  tubal  disease,  as  I  have  alread}^  shown. 

The  fourth  case.  Dr.  Sanger's,  is  the  least  doubtful,  for  the  patient 
recovered  from  the  operation;  but  the  mischief  recurred  and  proved 
fatal.  The  microscopical  report  comes  from  a  very  trustworthy  quarter. 
Professor  Sanger  calls  the  tumour  "  essentially  a  small-celled,  round- 
celled  sarcoma."     There  was  a  broad  ligament  cyst  on  the  left  side. 

A  remarkable  paper  was  recently  written  by  Dr.  Charles  Dixon-Jones, 
who  quotes  freely  from  Dr.  Janvrin's  report  of  case  3,  accepting,  it  is 
clear,  the  opinion  that  it  Avas  an  instance  of  sarcoma  and  not  inflam- 
mation. Dixon-Jones  received  from  Professor  Formad  of  Philadelphia, 
thirty-five  specimens  of  tubal  tumours  all  believed  to  be  cases  of  tubal 
pregnancy  removed  after  death  from  women  who  had  died  suddenl^^ 
They  were  selected  specimens  from  the  necropsies  of  over  3000  adult 
women.  Many  of  the  thirty-five  were  decomposed.  Of  those  found 
fit  for  microscopic  section  three  proved,  in  Dixon-Jones'  opinion,  to  be 

1  Both  tumours  might  have  been  sarcoma  originally.  See  Godlee,  "Blood-cyst 
developed  in  a  Sarcoma.     Trans.  Path.  Soc.  vol.  xxvi.   p.  193. 


826  SVSTEJ/  OF  GYXJECOLOGY 

malignant  tumours  of  the  tube-wall,  and  not  tubal  pregnancies.  Intra- 
peritoneal htemorrhage  is  assumed  as  the  cause  of  the  sudden  death  in 
all  the  thirty-five  cases.  In  the  three  supposed  malignant  cases  there 
certainh-  -was  evidence  of  rupture  of  the  tubal  wall  and  hasmorrhagic 
infarction  into  the  substance  of  the  new  growth.  The  large  vessels 
involved  in  the  sarcoma  tissue  seem  to  have  yielded.  Dixon-Jones 
describes  the  three  specimens  as  (1)  "  globo-myeloma  (large  round-celled 
sarcoma) " ;  (2)  "  spindle  myeloma  (large  spindle-celled  sarcoma  of 
Virchow)  " ;   (3)  ''  melanotic  myeloma  (melanotic  sarcoma  of  Virchow)." 

Xo  pathologist  could  accept  unconditionally  the  opinion  that  these 
morbid  specimens  were  really  sarcomas.  The  clinical  histories  are  hypo- 
thetical. The  alleged  discovery,  in  so  limited  a  number  of  specimens,  of 
three  cases  of  a  rare  disease,  the  very  existence  of  which  is  still  disputed, 
is  in  itself  suspicious.  Where  else  do  we  hear  of  a  case  of  sudden 
death  from  rupture  of  a  sarcomatous  tube  ?  Old  inflammatory  deposits 
mixed  with  blood-clot  and  relics  of  tubal  gestation  may  readily  deceive 
the  pathologist. 

Finally,  it  is  clear  that  primary  sarcoma  of  the  tube  as  a  disease  is 
very  rare,  and  as  a  subject  highly  obscure.  The  evidence  of  Sanger  and 
Landau  establishes  the  fact  that  a  tumour  of  this  pathological  class  may 
involve  the  mucous  membrane.  Senger's  case  seems  to  support  this 
evidence.  Janvrin's  shows  that  sarcoma  may  be  confined,  or  almost  con- 
fined, to  the  deeper  part  of  the  tubal  wall.  Sanger  seems  inclined  on 
that  account  to  place  that  case  (No.  3)  in  a  distinct  sub-class.  We  have 
not  sufficient  evidence,  however,  to  prove  that  sarcoma  does  not  always 
arise  in  the  interior  of  the  tubal  wall,  as  the  pathologist  would  naturally 
expect.  In  2  and  4,  where  the  mucosa  was  involved,  the  disease  was 
advanced.  The  difficulty  of  distinguishing  between  new  growths  and 
inflammatory  deposit  greatly  complicates  the  sarcoma  question  on  account 
of  the  well-established  frequency  of  true  inflammatory  changes  preceding 
the  development  of  a  true  neoplasm.  Nothing  can  be  decided  until  more 
clinical  evidence  is  at  our  disposal.  In  the  meantime  there  can  be  no 
doubt  that  the  timely  removal  of  a  suspected  sarcoma  of  the  tube  is 
justifiable. 

Deciduoma  Malignum  of  the  Tube.  —  Two  cases  of  this  remarkable 
disease  have  been  described,  both,  in  Professor  Sanger's  oi)inion,  seeming 
quite  authentic.  Deciduoma  malignum,  or  malignant  degeneration  of 
relics  of  the  fVjetal  envelopes  and  appendages,  is  a  disease  which  has  been 
repeatedly  noted  dui'ing  the  past  ten  years  on  the  Continent.  Tlie  very 
existence  of  this  disease,  as  distinct  from  ordinary  sarcoma  following 
pregnancy,  has  recently  been  disputed  in  this  country  (50a).  If  malig- 
nant degeneration  of  a  piece  of  j)lacenta  or  chorion  can  really  produce  a 
large  uterine  tumour  followed  V)y  metastatic  deposits  in  the  abdominal 
and  thoracic  viscera,  it  is  not  surprising  that  a  similar  malignant  change 
may  occur  in  a  tu})al  sac  in  ecto])ic  fjregnancy. 

Sanger  holds  that  the  possiljility  of  (hiciduoma  malignum  following 
tubal  jH'cgnancy  being  established,  we  have  one  more  argument  not  only 


DISEASES    Of  THE  FALLOPIAN    TUBES  827 

for  active  interference  in  cases  of  abnormal  gestation,  but  also  for  the 
extirpation  of  tubal  moles  and  appendages  where  "  tubal  abortion  "  has 
occurred.  I  leave  the  question  to  the  consideration  of  obstetricians  ; 
the  subject  of  tubal  gestation  is  treated  in  another  section  of  this  work. 
I  felt,  however,  that  deciduoma  malignum  must  be  mentioned  under  the 
head  of  malignant  new  growths  affecting  the  tube. 

Finally,  I  say  "malignant,"  not  "cancerous,"  or  "sarcomatous," 
because  the  few  authorities  who  have  observed  deciduoma  are  not  quite 
agreed  as  to  the  precise  nature  of  its  malignancy. 

Albax  Dorax. 

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828  SYSTEM  OF  GYNECOLOGY 

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835 


836  SYSTEM   OF  GYNECOLOGY 


DISEASES   OF  THE  OVAEY 

Tumours  of  the  Ovary.  —  Solid  tumours  of  the  ovary  arise  from 
the  connective-tissue  stroma ;  cystic  tumours,  on  the  other  hand,  although 
their  walls  and  a  large  part  of  their  solid  contents  have  a  similar  origin, 
appear  to  arise  either  from  Graafian  follicles,  or  from  ingrowths  of  the 
germ  epithelium  which  covers  the  ovary. 

I  propose  in  this  article  to  avoid,  as  far  as  possible,  the  minute  sub- 
division of  ovarian  tumours  which  has  been  the  first  and  the  natural 
result  of  the  labours  of  investigators  in  a  new  field;  and  also  the  some- 
what speculative  views  of  the  origin  of  the  different  varieties.  While, 
for  the  most  part,  the  characteristic  features  of  the  principal  classes  are 
readily  recognisable,  the  variations  and  combinations  of  them  are  so 
numerous  that,  in  the  present  state  of  our  knowledge,  it  is  often  not 
practicable  to  classify  a  particular  tumour  with  certainty.  Innocent 
kinds  pass  by  almost  insensible  gradations  into  malignant ;  solid  tumours 
develop  cysts,  and  cystic  tumours  develop  solid  masses ;  papillomatous 
growths  develop  both  in  cystic  tumours  and  on  the  surface  of  the  ovary 
without  any  cystic  formation ;  and  cysts  with  papillomatous  or  dermoid 
contents  occur  either  alone,  or  as  parts  of  tumours  of  different  kinds. 

I  propose,  therefore,  to  describe  first  the  characters  common  to  all, 
and  then  to  point  out  some  of  the  features  of  special  kinds. 

The  first  requirement  for  a  systematic  investigation  of  ovarian 
tumours  is  undoubtedly  a  knowledge  of  the  structure  of  the  healthy 
ovary.  The  absence  of  this  knowledge,  and  the  inherent  difficulties  of 
the  subject,  have  led  and  still  lead  to  much  difference  of  opinion  on 
points  which  by  this  time  should  have  been  settled. 

The  bulk  of  the  solid  parts  of  all  ovarian  tumours  is  composed  of 
well-developed  connective  tissue,  or  of  a  spindle-celled  stroma  identical 
with  that  of  the  normal  ovary,  or  of  both  these  constituents.  The 
spindle  cells  have  been  identified  by  some  observers  as  connective-tissue 
corpuscles;  by  others  as  unstriped  muscle ;  or  in  some  cases  as  sarcoma 
cells.  The  fact  that  the  spindle  cells  of  such  tumours  are  for  the  most 
part  indistinguishable  from  those  of  the  normal  stroma,  and  that  in  solid 
tumours  the  development  of  these  cells  into  fully  formed  connective- 
tissue  may  often  \)G  distinctly  traced,  should  lead  the  observer  to  hesitate 
before  d('scril)ing  a  tumour  as  a  myoma,  or  as  a  spindle-celled  sarcoma, 
on  anatomical  evidence  alone. 

The  connective  tissue  of  cyst  walls  varies  greatly  in  vascularity;  the 
greater  the  bulk  of  solid  tissue  the  more  vascular  it  is :  the  walls  of 
unilocular  cysts  with  fluid  contents  are  often  parchment-like  and  almost 
bloodless. 

All  cystic  tiiinoiirs,  with  tlie  exception  of  those  formed  by  degenera- 
tion from  solid  growths,  are  lined  more  or  less  by  epithelial  structures, 


DISEASES    OF   THE    OVARY  837 

upon  which  their  cystic  character  depends.  Now,  excluding  the  lin- 
ing of  the  vessels,  epithelium  is  present  in  the  normal  ovary  in  two 
forms  only :  firstly,  as  the  germ  epithelium  covering  almost  the  entire 
surface  of  the  organ;  and,  secondly,  as  the  epithelium  lining  the 
Graafian  follicles.  These  parts  we  should  naturally  regard,  therefore, 
as  the  seats  of  development  of  all  cystic  tumours.  No  author  now 
regards  the  epithelium  of  the  vessels  as  the  source  of  cystic  tumours ; 
and  the  evidence  of  many  observers  is  accumulating  in  favour  of  the 
follicular  source  of  most  ovarian  cysts.  We  are,  however,  still  unable 
to  explain  the  great  differences  which  are  found  not  only  in  the  several 
tumours,  but  also  in  the  several  compartments  of  the  same  tumour. 

Hydrops  FolUculorum. — The  simplest  cysts  are  the  small  unilocular 
dilated  follicles  known  by  this  name.  They  are  generally  multiple  and 
small  in  size ;  although  occasionally  a  single  cyst  may  be  as  large  as  a 
fist,  a  man's  head,  or  even  yet  larger.  When  the  cysts  are  minute,  the 
ovary  may  be  but  little  enlarged,  some  of  them  projecting  on  the  sur- 
face, others  lying  deep  in  the  stroma.  The  fluid  contained  in  these 
cysts,  as  in  all  ovarian  cysts,  may  be  clear  or  blood-stained.  The  lining 
membrane  is  clear  and  transparent,  and  covered  with  columnar  epithe- 
lium. As  a  rule  the  cysts  are  few  in  proportion  to  the  amount  of 
stroma;  but  occasionally  they  are  very  numerous,  and  the  stroma  so 
scanty  that  the  ovary  is  converted  into  a  small  mass  of  delicate  cysts. 

It  is  quite  common  to  meet  with  ovaries,  otherwise  healthy,  with  a 
single  unilocular  cyst  as  large  as  a  pigeon's  or  a  small  hen's  egg ;  it  is 
situated  usually  at  the  outer  extremity. 

The  causation  of  these  cysts  is  probably  a  very  simple  matter.  It  is 
believed  that  the  normal  rupture  of  the  follicles  is  prevented  by  a 
thickening  or  undue  toughness  of  their  walls,  resulting,  perhaps,  from 
inflammation ;  and  this  leads  to  an  increased  accumulation  of  their  fluid 
contents.  Occasionally  ova  can  be  detected  in  them.  Such  C3^sts  have 
been  known  to  occur  in  the  fcetal  ovary. 

These  forms  of  cystic  ovary  rarely  give  rise  to  symptoms,  or  interfere 
with  the  normal  functions  of  the  organ ;  menstruation,  ovulation,  and 
pregnancy  take  place  in  their  usual  course.  Progressive  enlargement 
beyond  a  moderate  size  is  not  common,  and  any  of  the  cysts  may  rupture 
and  be  cured  spontaneously. 

Cystic  Corpora  Lutea. —  These  also  are  unilocular  cysts,  and  are  usually 
of  the  size  of  a  pigeon's  egg ;  though  occasionally  they  have  been  found  as 
large  as  a  small  apple  (Gottschalk  and  Nagel).  They  were  first  described 
by  llokitansky.  The  wall  is  comparatively  thick,  and  is  lined  by  the 
yellow  and  apparently  folded  membrane  characteristic  of  these  bodies, 
altered  by  pressure  and  stretching,  and  stained  by  the  blood  which  usually 
forms  their  contents.  Careful  observation  of  this  lining  membrane  by 
the  eye  and  the  microscope  will  distinguish  them  from  other  small  cysts 
containing  blood.  It  will  not  be  possible  to  explain  the  occurrence  of 
these  cysts  until  our  knowledge  of  the  natural  history  of  normal  corpora 
lutea  is  more  complete.     I  have  examined  specimens  which  have  led  me 


838  SVST£M    OF  GYX.^COLOGY 

to  believe  that  a  corpus  luteum  may  be  developed  in  an  unruptured  follicle ; 
if  tbis  be  correct,  dropsy  with  subsequent  haemorrhage  from  the  very 
vascular  lining  membrane  is  a  reasonable  explanation  of  the  cysts. 

Proliferating  Cystoma. — I  now  come  to  afar  more  difficult  and  com- 
plicated class,  the  various  forms  of  proliferating  cystoma.  This  class 
comprises  the  great  bulk  of  ovarian  cystic  tumours.  They  vary  greatly 
in  size :  occasionally  they  are  met  with  at  an  early  stage,  and  are  then 
very  small ;  if  not  removed  by  operation  they  may  attain  enormous 
dimensions,  so  that  the  emaciated  woman  may  almost  appear  to  be  an 
appendage  to  the  tumour. 

These  tumours  are  composed  of  agreater  or  smaller  number  of  primary 
cysts  which  contain  secondary  cysts  in  their  walls,  or  projecting  in  more 
or  less  solid  masses  into  their  cavities.  There  is  every  variety  of  size  in 
th^  primary  and  secondary  cysts.  Usually  one  or  more  greatly  exceed 
the  others  in  balk:  many  of  the  cysts  rupture  and  communicate  with 
each  other  by  small  or  large  openings  in  the  septa ;  in  consequence  some 
disappear,  and  are  recognised  by  an  orifice  in  a  septum  closely  com- 
pressed against  the  inner  surface  of  the  larger  cysts.  The  very  large 
cavities  are  usually,  if  not  always,  formed  in  this  manner. 

A  cyst  composed  of  a  few  thin-walled  cavities  may  by  fusion  become 
practically  if  not  strictly  unilocular. 

Fusion  of  cystic  tumours  of  both  ovaries  may  also  occur  in  the  same 
way,  and  form  a  single  tumour,  the  nature  of  which  may  be  recognised 
by  the  presence  of  two  characteristic  pedicles,  one  on  each  side  of  the 
uterus. 

Structure.  —  The  cyst  walls  are  composed  mainly  of  dense,  more  or 
less  vascular  connective  tissue,  arranged  chiefly  in  bundles  of  long  white 
fibres ;  the  most  recently  formed  parts  contain  also  the  characteristic 
spindle  cells  of  the  ovarian  stroma,  and  in  the  neighbourhood  of  the 
pedicle  non-striped  muscle  fibres  have  been  found  by  Olshausen  and 
others. 

The  walls,  therefore,  if  at  all  thick,  are  very  tough  and  strong ;  some, 
however,  being  naturally  thin,  or  being  weakened  by  papillomatous 
growths,  secondary  cysts,  or  some  partial  degeneration,  may  rupture 
from  very  slight  or  inappreciable  exciting  causes. 

The  epithelium  is  polymorphous;  cylindrical,  ciliated,  and  goblet 
cells  being  the  principal  forms:  the  cells  are  sometimes  quite  irregular  in 
shape,  sometimes  flattened,  and  sometimes  even  absent.  Usually  they 
form  a  single  layer,  sometimes  several  layers.  Where  proliferation  is 
taking  place  cup-shaped  depressions  occur  which,  gradually  invading  the 
cyst  wall  and  becoming  closed  at  their  mouths,  form  secondary  cysts. 
G-roups  of  cysts  thus  formed  may  project  into  the  principal  cavity  and 
make  semi-solid  masses,  which  not  rarely  attain  considerable  size.  On 
section  these  masses  are  seen  to  be  composed  of  small  secondary  cysts, 
and  they  may  thus  be  distinguished  from  the  papillomatous  growths 
occasionally  found  in  these  cysts. 

Much  less  frequently  there  are  found  in  some  of  the  cavities  of  these 


DISEASES    OE   THE    OVARY  839 

tumours  connective-tissue  buds  covered  with  columnar  epithelium  in  the 
form  of  dendritic  masses  which  may  fill  the  containing  cysts.  vSome- 
times  they  perforate  the  wall  of  the  cyst  and  spread  to  adjacent  ones ; 
or,  if  the  main  cyst  wall  be  perforated,  they  spread  over  the  adjacent 
peritoneum,  and  particles,  becoming  detached,  may  be  carried  to  distant 
parts  of  the  abdominal  cavity  and  grow  there.  Such  papillomatous 
masses  may  be  found  with  three  different  characters:  —  (i.)  Developing 
in  certain  loculi  of  otherwise  typical  proliferating  cysts,  (ii.)  Develop- 
ing in  the  principal  cyst  and  in  any  secondary  cyst  —  such  tumours  are 
as  a  rule  not  very  large,  and  show  a  tendency  to  invade  the  broad  liga- 
ments, (iii.)  Developing  on  the  surface  of  the  ovary  without  any  evi- 
dence of  having  been  previously  contained  in  a  cyst.  Such  cases  are 
very  rare,  and  are  well  described  as  ''surface-papillomas." 

A  different  origin  is,  of  course,  possible  in  some  cases  of  surface- 
papilloma;  the  growths  may  originally  have  been  developed  in  a  cyst 
which  was  perforated  and  has  entirely  disappeared. 

Microscopic  sections  of  these  masses  closely  resemble  transverse 
sections  of  the  middle  and  outer  parts  of  the  Fallopian  tube ;  there  is 
little  tendency  to  the  formation  of  cysts.  Small  sand-like  concretions, 
called  psammomas,  are  frequently  present  in  them,  and  are  sometimes 
also  found  in  the  walls  of  proliferating  cysts. 

It  will  be  noticed  that  the  proliferating  cj^sts  are  lined  almost 
uniformly  by  structures  closely  resembling  certain  mucous  membranes 
with  their  simple  tubular  glands  ;  and  as  a  result  the  term  "  glandular  " 
has  been  applied  to  them.  Waldeyer,  Eland  Sutton,  and  others  have 
drawn  attention  to  these  resemblances. 

Papillary  cysts  are  more  frequently  bilateral  than  the  proliferating 
cysts.  The  rare  surface-papilloma  is  generally  accompanied  by  abundant 
hydroperitoneum.  In  the  latter  case  Olshausen  states  that  the  cubical 
surface-epithelium  of  the  ovary  is  directly  continuous  with  and  gradu- 
ally lengthens  into  the  columnar  epithelium  of  the  papilloma. 

Recently  AVhitridge  Williams  (37)  has  carefully  investigated  the 
])apillary  tumours  of  the  ovary.  He  is  of  opinion  that  only  a  small  pro- 
portion of  them  invade  the  broad  ligaments,  while  at  least  half  of  them 
are  bilateral.  He  finds  that  they  are  lined  by  a  single  layer  of  columnar 
cells,  except  at  points  where  new  papillae  are  being  formed,  when  the 
layers  are  multiple.  The  epithelium  is  often,  but  not  invariably  ciliated. 
He  also  finds  the  same  characters  in  surface-papilloma,  of  which  he  has 
collected  twenty-six  well-described  cases.  The  entire  surface  of  the 
organ  may  be  covered  with  papilla?,  the  ovary  itself  being  almost 
unchanged ;  although  at  times  epithelial  processes  and  duct-like  struct- 
ures may  be  found  to  extend  into  the  stroma,  and  from  these  papilloma- 
tous cysts  may  arise  in  the  substance  of  the  ovary.  Psammomas  are 
j)resent  in  large  numbers.  He  believes  that  the  surface  papillomas 
arise  from  the  germ  epithelium. 

Contents.  —  The  fluid  contained  in  proliferating  cysts  is  usually  vis- 
cid ;  but  it  varies  greatly  in  consistence  and  colour  in  different  tumours, 


840  SYSTEM   OF  GYNAECOLOGY 

and  even  in  different  cavities  of  the  same  tumour.  In  some  it  is  so  viscid 
that  it  will  not  flow,  and  has  to  be  removed  in  handfuls  from  the  cysts 
or  the  peritoneal  cavity ;  in  others  it  is  quite  tliin,  and  every  inter- 
mediate degree  of  viscidity  may  be  found.  The  fluid  is  at  first  colour- 
less, and  either  transparent  or  opaque ;  but  from  admixture  with  blood 
and  subsequent  changes,  the  colour  may  vary  through  every  shade  of 
blood-red  to  brown,  green,  or  yellow. 

The  specific  gravity  varies  from  1'002  to  1-020,  the  average  being 
perhaps  about  1-012;  higher  that  is  than  in  the  case  of  broad  ligament 
cysts,  and  some  papillomatous  cysts. 

Histologically  the  fluid,  however  viscid,  is  structureless ;  though  at 
times  a  delicate  connective-tissue  reticulum  may  be  found  in  colloid 
material.  Blood  corpuscles  are  often  present,  and  epithelial  cells 
which  vary,  of  course,  in  character,  and  in  the  different  degrees  of 
degeneration.  Sometimes  crystals  of  cholesterin  are  found.  The 
reaction  is  neutral  or  alkaline.  Various  forms  of  albumin  are  present 
in  solution,  such  as  metalbumin,  paralbumin,  albumin  peptone,  and  so 
forth ;  to  these  bodies  the  viscidity  of  the  fluid  is  due. 

Dermoid  Structures  in  Ovarian  Cysts.  —  These  form  a  very  remarkable 
and  not  common  variety  of  ovarian  tumours  (3-5  per  cent  acccording  to 
Olshausen).  Both  structurally  and  clinically  they  present  characteristic 
features,  by  which  they  may  he  recognised.  There  are  three  principal 
varieties  of  these  tumours,  which  are  always  cystic :  (i.)  A  unilocvilar 
cyst  possessing  the  characteristic  features,  (ii.)  A  cyst  with  two  or  more 
cavities  each  with  characteristic  dermoid  contents ;  the  component  cysts 
having  probably  arisen  independently,  not  by  proliferation,  (iii.)  An 
ordinary  proliferating  cyst,  one  or  more  cavities  of  which  contain  char- 
acteristic dermoid  structures.  Out  of  thirty-one  dermoid  cysts  Doran 
records  four  of  this  kind. 

The  anatomical  structures  characteristic  of  these,  as  of  all  dermoid 
tumours,  are  portious  of  true  skin  present  in  the  cyst  wall.  Occasionally, 
perhaps,  the  whole  cyst  may  be  lined  with  cutaneous  structures,  but 
usually  there  is  only  a  relatively  small,  well-defined  patch  of  skin. 

Section  of  these  patches  reveals  the  histological  characters  of  true 
skin ;  often  with  the  hair,  sweat  and  sebaceous  glands  resting  on  a  layer  of 
subcutaneous  fat  which  unites  it  to  the  cyst  wall.  Teeth,  bone,  cartilage, 
and,  much  less  frequently,  other  structures  —  such  as  non-striped  muscle 
and  nerve  tissue  —  may  be  found  in  different  parts  of  the  cyst  wall. 

The  dermoid  mass  sometimes  curiously  resembles  the  mamma  in 
shape,  and  may  even  present  a  rudimentary  nipple,  as  described  by  Von 
Velits,  Bland  Sutton,  and  others.  The  mass  is,  however,  composed  not 
of  mammary  gland  tissue,  but  of  fat;  the  gland  tubes  present  being 
obviously  modified  seVjaceous  and  sudori])arous  glands. 

The  hair  is  developed  from  follicles  in  tin;  ordinary  way,  and  may 
grow  to  a  considerable  length  :  it  is  often  detached,  and  then,  if  long, 
may  be  coiled  uy)  into  l)alls;  or  if  short,  mixed  u])  with  the  other 
contents  of  the  cyst     The  colour  l^ears  no  necessary  relation  to  that  of 


DISEASES   OF   THE    OVARY 


the  normal  hair  of  the  individual.  Irregular  plates  and  masses  of  bone, 
and  occasionally  nodules  of  cartilage,  are  found  embedded  in  the  cyst 
wall.  Teeth  may  be  found  projecting  from  these  bony  plates;  they  are 
often  irregular  in  shaj)e  and  vary  greatly  in  number :  usually  they  are 
few,  but  as  many  as  300  have  been  described  by  Autenreich.  The 
characters  of  these  dermoid  teeth  have  been  fully  described  by  Mr. 
Bland  Sutton.  Nails  have  been  found  by  Cruveilhier  and  others.  Mr. 
Knowsley  Thornton  records  a  dermoid  containing  a  mass  like  a  mal- 
formed limb  with  long  nails  at  the  extremity. 

Dermoid  cysts  usually  contain  a  thick,  white,  pultaceous  or  putty-like 
substance,  consisting  of  fat,  cholesterin,  ej)ithelial  cells  and  hair,  which 
may  be  rolled  up  into  coils  or  balls.  The  fat  is  sometimes  fluid  at  the 
body  temperature.  Occasionally  large  numbers  of  small  solid  balls  of  fat 
are  found.  Bland  Sutton  has  described  one  containing  several  hundreds 
of  these  bodies  ;  each  one  examined  had  a  short  hair  coiled  up  within  it. 

Dermoid  cysts,  like  the  other  varieties,  may  contain  sarcomatous  or 
carcinomatous  masses ;  and  there  is  reason  to  believe  that  they  are 
more  often  followed  by  malignant  secondary  growths  than  are  the  other 
forms  of  cysts. 

A  remarkable  case  of  Martini's  is  recorded  by  Kolaczek,  who  on 
removing  a  dermoid  cyst  found  the  peritoneum  studded  with  numbers 
of  small  yellowish  bodies  the  size  of  peas,  many  of  which  contained  a 
thin  woolly  hair  attached  to  the  peritoneum.  He  supposed  that  they 
arose  as  a  result  of  rupture  of  the  cyst. 

Hydatids  of  the  Ovary.  —  There  is  very  great  doubt  whether  any  of 
the  cases  so  recorded  are  really  hydatids  of  the  ovary ;  most  probably 
they  are  examples  of  hydatid  cysts  involving  but  not  originating  in  the 
ovary. 

Schultze,  in  1893,  operated  on  a  woman  32  years  of  age,  and  re- 
moved from  the  abdomen  30  hydatid  cysts :  the  largest  was  6  inches 
in  diameter,  and  the  right  tube  was  stretched  over  it;  it  Avas  apparently 
a  cyst  of  the  right  ovary.  The  left  ovary  and  tube  were  healthy. 
Several  cysts  had  to  be  left  behind,  but  the  patient  made  a  good 
recovery.  Schultze  admits  there  was  no  proof  that  the  disease  origi- 
nated in  the  ovary. 

Malignant  Groicths  in  Ovarian  Cysts.  —  The  presence  of  malignant 
masses  in  the  Avails  of  different  varieties  of  ovarian  cysts  has  already 
been  referred  to.  The  Avell-known  clinical  fact  that  a  certain  number  of 
women  die  from  malignant  disease  after  ovariotomy,  in  whom  at  the 
time  of  operation  the  tumour  was  thought  to  be  benign,  is  probably  to 
be  explained  by  the  non-recognition  of  such  malignant  masses. 

Landerer  gives  details  of  three  cases  of  proliferating  cystoma  with 
malignant  growths  in  the  walls.  In  two  there  were  secondary  growths 
in  the  tube  of  the  same  side,  and  in  one  both  tubes  were  affected. 
Secondary  nodules  were  also  found  in:  —  (i.)  The  utero-vesical  cellular 
tissue  and  broad  ligaments,  (ii.)  The  mesentery,  and  parietal  and 
visceral  peritoneum,     (iii.)  The  abdominal  surface  of  the  diaphragm. 


S42  SYSTEM   OF  GYNECOLOGY 

(iv.)  Tlie  retro-peritoneal,  inguinal,  mediastinal,  and  bronchial  glands. 
(V.)  The  parietal  and  pulmonary  pleura,     (vi.)  The  liver. 

The  growths  in  the  cyst  wall  Avere  carcinomatous,  arising  from 
proliferating  (glandular)  processes  of  the  lining  epithelium,  which  were 
hollow  or  in  some  places  filled  with  polymorphous  cells;  in  others  lined 
with  columnar  epithelium  or  dilated  into  small  cysts.  In  other  places 
well-marked  alveolar  cancer  was  present. 

In  such  cases  metastasis  occurs  through  the  blood  or  lymph  chan- 
nels, or  by  the  migration  of  detached  particles  to  distant  parts  of  the 
jieritoneal  cavit3^ 

Landerer  justly  remarks  that  if  apparently  simple  ovarian  cysts  ma}^ 
thus  become  the  seat  of  carcinomatous  growths,  it  is  wise  to  remove  all 
such  tumours,  however  small,  immediately  they  are  detected.  In  the 
case  of  papillomatous  cysts,  it  is  not  very  uncommon  at  the  time  of 
operation  to  find  that  secondary  papillomatous  growths  are  present  in  the 
parietal  or  visceral  peritoneum.  These  secondary  growths  probably 
arise  by  detachment  and  migration  of  papillomatous  particles  from  a  cyst 
w^hich  has  become  perforated,  and  from  which  papillomas  protrude. 
This  simple  explanation  does  not,  however,  apply  to  cases  in  which 
secondary  papilloma  has  been  found  upon  the  pleura;  in  such  cases 
distribution  must,  of  course,  occur  through  the  blood  or  lymph  channels 
as  in  the  case  of  true  malignant  metastasis.  Indeed,  it  seems  clinically 
established  that  papillomatous  cysts  are  more  nearly  allied  to  malignant 
disease  than  are  the  simple  proliferating  cysts.  It  is  a  curious,  but 
well-established  fact,  that  secondary  papillomas,  not  removed  at  the 
time  of  operation,  disappear  after  the  removal  of  the  principal  growth, 
and  in  no  way  prejudice  the  ultimate  result  of  the  operation. 

Bolid  tumours  of  the  ovary,  according  to  Olshausen,  form  about  5  per 
cent  of  all  ovarian  tumours.  Like  cystic  tumours  they  may  be  either 
innocent  or  malignant ;  they  may  also  undergo  cystic  degeneration. 

The  larger  innocent  tumours  are  composed  of  spindle-celled  tissue 
similar  to  that  of  the  normal  ovarian  stroma,  with  two  well-marked 
differences ;  namely,  the  tendency  to  develop  into  pure  fibrous  tissue, 
and  the  tendency  to  softening  of  the  fibres,  leading  to  the  formation  of 
cyst-like  cavities  like  those  which  occur  in  uterine  fibroids.  Cysts 
may  also  arise  by  lymphangiectasis.  Occasionally  calcification  is  met 
with. 

Solid  tumours,  whether  innocent  or  malignant,  are  often  bilateral; 
and  this  condition  is  therefore  no  important  evidence  of  malignancy. 

The  name  fibroma  is  obviously  correct  for  such  tumours  as  these ; 
those  who,  like  Mr.  Doran,  apply  the  name  myoma  must  satisfy  them- 
selves that  the  normal  ovarian  stroma  is  principally  non-striped  muscle. 

This  variety  of  tumour  is  distinctly  rare,  but  is  probal)ly  the  most 
common  form  of  solid  ovarian  tumour.  In  general  character  it  closely 
resembles  the  harder  utca-iue  lil)roiiiyoina:  there  is,  liowevcr,  one  clini- 
cal distinction  of  grtsat  iin])oi'tati(!C ;  iiainely,  that  they  are  frequently 
axjcompanied  by   hydroperitoneum.     ]5eing   very  slow  in  growth  and 


DISEASES   OF   THE    OVARY  843 

generally  discovered  early,  they  do  not  attain  a  very  large  size.  As  they 
are  formed  by  hyperplasia  of  the  whole  stroma,  they  maintain  the  gen- 
eral coutour  of  the  ovary.  As  a  rule  they  are  freely  movable,  having 
no  adhesions,  and  are  surrounded  by  fluid.  The  oviduct,  though  often 
thickened,  apparently  by  simple  hyperplasia,  is  not  stretched  over  the 
growth,  as  in  the  case  of  cystic  tvimours,  but  lies  free,  because  the  meso- 
salpinx is  not  opened  up  by  the  growth. 

The  tumours  sometimes  contain  small  cavities  or  cysts,  rarely  large 
ones ;  these  may  be  formed  by  dilated  follicles,  lymphangiectasis  or  soft- 
ening of  the  constituent  fibres  ;  proliferating  or  papiilomatous  cysts  have 
not,  I  believe,  been  met  with  in  the  same  ovary. 

There  is  a  peculiar  form  of  fibroma  of  the  ovary  which,  as  it  leads 
to  no  great  enlargement  of  the  ovary,  is  generally  met  with  in  the  dead- 
house,  or  accidentally  during  operations.  The  ovary  may  be  as  large  as 
a  small  hen's  egg,  and  is  irregular  in  shape.  On  section  the  enlargement 
is  seen  to  be  due  to  the  presence  of  one  or  more,  sometimes  of  many 
oval  bodies  the  size  of  peas  or  beans,  well  defined  from  the  rest  of  the 
stroma  by  being  paler  in  colour,  and  showing  a  sinuous  arrangement  of 
the  fibre  bundle.  They  are  found  to  consist  of  well-developed  white 
fibrous  tissue,  which  stains  with  difficulty,  and  is  less  vascular  than  the 
surrounding  stroma.  They  are  identical,  except  in  size,  with  corpora 
lutea  in  their  penultimate  stage ;  and  undoubtedly  they  are  corpora  lutea 
which  have  undergone  hypertrophy  instead  of  atrophy.  The  largest 
specimen  I  have  examined  was  the  size  of  a  walnut ;  it  contained  a  con- 
siderable number  of  these  bodies. 

They  have  also  been  described  by  Rokitansky,  Klebs,  and  Klob.  In 
Klob's  case  the  tumour  was  as  large  as  the  foetal  head.  In  Eokitansky's 
cases  the  largest  was  no  bigger  than  a  walnut. 

Dr.  Mary  Dixon-Jones  has  described  and  figured  this  form  of  tumour 
under  the  appropriate  name  of  gyroma;  but  she  believes  these  growths  to 
be  closely  connected  with  those  described  as  endothelioma  of  the  ovary, 
and  that  they  are  developed  from  corpora  lutea  when  found  in  the  cortex, 
from  endothelium  when  found  in  the  medulla. 

The  term  "endothelioma"  was  first  applied  by  Leopold,  in  1874,  to 
a  peculiar  form  of  fibroma  of  the  ovary,  containing  numerous  alveolar 
spaces  packed  with  epithelioid  cells.  He  traced  the  origin  of  these  spaces 
to  dilatation  of  lymphatic  and  capillary  channels,  with  proliferation  of 
their  endothelium  ;  hence  the  name.  Similar  tumours  have  been  since 
described  by  Marchand,  Rosthorn,  Amann,  and  others.  The  last  author 
made  the  interesting  observation  that  certain  typical  sarcomas  of  the 
ovary  could  be  traced  back  to  proliferation  of  the  adventitia  of  the 
smaller  vessels,  others  to  proliferation  of  the  endothelium  of  lymphatics 
and  capillaries.  Although  there  is  much  still  to  be  learned  about  these 
tumours,  it  seems  well  established  that  they  really  do  arise  from  the 
walls  of  lymphatics  and  blood-vessels,  and  that  they  must  be  regarded 
as  closely  allied  to  sarcoma. 

Sarcomaofthe  Ovary. — All  authorities  are  agreed  that  our  knowledge 


844  SYSTEM   OF  GYXyECOLOGY 

of  this  form  of  malignant  growth  is  very  imperfect.  Primary  sarcoma 
and  carcinoma,  in  the  form  of  solid  tumour,  are  rare. 

Olshausen  says  that  "  the  spindle-celled  form  of  sarcoma  is  the  most 
common ;  mixed  round  and  spindle-celled  forms  are  met  with,  but  true 
round-celled  sarcoma  is  very  rare." 

The  consistence  of  these  tumours  varies  much ;  generally  they  con- 
tain cysts,  and  in  size  they  may  equal  the  foetal  head  at  term.  The 
bundles  of  spindle  cells  do  not  differ  materially  from  those  of  the  nor- 
mal stroma,  and  between  them  are  often  large  numbers  of  round  cells. 
These  tumours  are  closely  related  on  the  one  hand  to  fibroma,  and  on 
the  other  to  adenoma  and  carcinoma. 

Sarcoma  cf«'cmomatos?(m  has  been  described  by  Spiegelberg,  who  says, 
"  The  tumours  consist  for  the  most  part  of  rovmd-celled  sarcoma.  In 
certain  parts  are  large  alveoli  separated  by  a  very  vascular  connective 
tissue,  and  containing  large  cells  undergoing  fatty  degeneration,  the 
whole  being  quite  like  carcinoma." 

Secondary  sarcomatous  growths  are  found  most  frequently  in  the 
stomach,  liver,  intestines,  pleura,  and  peritoneum. 

Mr.  Bland  Sutton  says,  "  It  is  important  to  remember  that  the  ma- 
jority of  solid  ovarian  tumours  classed  in  museums  as  fibromata  are 
examples  of  sarcomata."  This  statement  requires  further  proof  before 
it  can  be  accepted ;  it  is  at  least  certain  that  many  tumours  classed  as 
sarcoma  are  really  fibroma.  Sutton  also  says  that  sarcoma  of  the  ovary 
grows  very  rapidly;  this  forms  a  very  important  clinical  distinction,  as 
fibromas  grow  very  slowly. 

What  is  needed  to  settle  these  questions  is  that  every  solid  ovarian 
tumour  shall  be  carefully  examined  by  a  competent  histologist,  and  its 
characters  recorded  with  the  after  histories  of  the  patients,  which,  un- 
less death  occur  soon  from  some  other  disease,  will  give  the  most  impor- 
tant evidence  as  to  the  malignancy  or  otherwise  of  the  tumour. 

Carcinoma  of  the  ovary  is  still  rarer  than  sarcoma;  as  already  stated, 
however,  carcinomatous  growths  are  not  infrequently  met  with  in  cystic 
tumours.  According  to  Olshausen  the  disease  in  50  per  cent  of  cases  is 
bilateral,  and  the  medullary  form  is  the  most  common.  The  tumour 
may  be  as  large  as  a  man's  head. 

Mr.  Shattock  has  recorded  a  case  of  columnar-celled  cancer  of  the 
ovary,  forming  a  large  tumour  11  inches  by  5  inches;  this  variety  is, 
however,  very  rare. 

The  greater  number  of  recorded  cases  are  clearly  secondary ;  but 
there  is  no  doubt  that  cancer  may  arise  primarily  in  the  ovary.  Bland 
Sutton  points  out  that  as  typical  adenoma  is  met  with  in  the  ovaiy 
there  is  reason  to  believe  that  cancer  may  also  occur  there ;  for  experi- 
ence shows  that  wherever  adenoma  occurs  cancer  may  also  appear. 
Positive  observations  have,  however,  been  made  by  Steffeck  and  others. 

Stcffeck  was  able,  in  one  instance,  to  trace  to  his  satisfaction  the  ori- 
gin of  the  cancer  to  the  epithelial  lining  of  the  (Graafian  follicles,  thus 
proving  conclusively  the  p(jssibility  of  a  primary  origin  of  the  disease 


DISEASES    OF   THE    OVARY  845 

in  the  ovary.  Doran  records  a  case  of  alveolar  cancer  in  a  girl  of 
fifteen. 

Cysts  of  the  Broad  Ligament.  —  A  considerable  number  of  cysts,  re- 
moved by  ovariotomy  (11  per  cent  according  to  Olshausen),  are  found  to 
occupy  one  or  other  broad  ligament.  Some  of  these  have  arisen  in  the 
ovary  and  gradually  invaded  the  broad  ligament ;  such  cysts  have  prob- 
ably originated  near  the  hilum,  although  not  necessarily  in  the  paro- 
ophoron. Both  proliferating  and  dermoid  C5^sts  luay  be  thus  found  in 
the  broad  ligament.  The  greater  number,  however,  arise  in  the  broad 
ligament,  are  independent  of  the  ovary,  and  have  distinctive  characters. 
They  are  thin-walled  and  usually  unilocular ;  although  occasionally  they 
contain  a  few  distinct  cavities,  and  possess  a  loosely  attached  coat  of 
peritoneum  which  can  easily  be  separated  from  the  true  cyst  wall.  They 
contain  a  clear  or  opalescent  watery  fluid  of  low  specific  gravity  (1-002  to 
1-008),  which  contains  chlorides  but  no  albumin.  The  epithelial  lining 
may  be  columnar  (when  it  is  often  ciliated),  or  cubical ;  at  times  the 
cyst  is  lined  merely  by  a  thin  layer  of  hyaline  substance. 

The  oviduct  is  stretched  over  the  cyst,  and  often  is  greatly  elongated ; 
it  does  not  communicate  with  the  cyst  cavity  as  in  tubo-ovarian  cj^sts. 
It  always  remains  patent. 

The  ovary  may  be  found  free,  or  stretched  and  flattened  against  the 
cyst  wall. 

The  smaller  and  medium-sized  cysts  are  sessile,  being  contained 
entirely  within  the  broad  ligament;  the  larger  cysts  often  develop  a 
broad  pedicle  easily  dealt  with  surgically. 

Mr.  Doran  has  carefully  investigated  and  described  an  uncommon  form 
of  broad  ligament  cyst,  namely,  the  papillary  form,  identical  with  papillary 
cysts  of  the  ovary.  He  believes  that  they  all  arise  from  the  parovarium ; 
those  of  the  broad  ligament  from  the  vertical  tubes  of  that  body,  those 
of  the  ovary  from  the  prolongation  of  the  parovarium  into  the  hilum. 
Doran  also  points  out  that  no  case  of  proliferating  cyst  of  the  broad 
ligament  has  ever  been  described  in  which  the  ovary  was  not  the  seat 
of  origin.  The  common  broad  ligament  cysts,  he  believes,  are  de- 
veloped outside  the  parovarium  ;  so  that  the  name  parovarian  cannot  be 
accurately  applied  to  them. 

Minute  cysts  are  also  often  found  above  the  tube  and  in  the  meso- 
salpinx, quite  distinct  from  the  parovarium;  also  cysts  may  be  formed 
by  distension  of  the  hydatid  of  Morgagni.  None  of  these,  however, 
attains  such  a  size  as  to  be  clinically  recognisable. 

Etiology. — The  investigation  of  the  origin  of  ovarian  tumours  in- 
cludes two  distinct  parts :  (i.)  The  anatomical  structures  from  which 
they  arise  ;  (ii.)  The  conditions  Avhich  cause  them.  Of  the  latter  subject 
we  know  nothing;  and  there  is  nuu-h  difference  of  opinion  and  un- 
certainty concerning  the  former.  It  is  not  worth  while,  in  this  article, 
to  do  more  than  recapitulate  briefly  the  views  of  the  most  important 
observers. 

It  is  obvious  that  the  chief  difficultv  lies  in  determining  the  origin 


846  SYSTEM   OF   GYNECOLOGY 

of  tlie  epithelial  structures,  wliich  for  the  most  part  determine  the  char- 
acters of  the  cystic,  papillary,  and  carcinomatous  tumours.  The  connec- 
tive tissue,  and  such  unstriped  muscle  as  may  be  present,  are  without 
doubt  developed  from  these  elements  of  the  ovarian  stroma. 

Hyaline  degeneration  of  blood-vessels,  of  abortive  follicles,  and  of 
corpora  lutea  have  been  regarded  by  some  authors  as  important  factors 
in  the  origin  of  ovarian  tumours ;  but  I  am  unable  to  regard  this 
passive  melting  of  degenerating  tissues  as  having  any  but  a  subordinate 
importance  in  relation  to  structures  bearing  such  evidence  of  vigorous 
growth  as  do  most  ovarian  tumours. 

With  the  exception  of  the  endothelium  of  the  vessels,  the  only 
epithelium  that  exists  in  the  ovary  is  (a)  the  germ  epithelium  which 
covers  the  ovary  at  all  stages,  and  from  which  (6)  the  epithelium  of 
the  Graafian  follicles  is  probably  derived,  and  (c)  the  epithelium  of  the 
parovarian  tubes  prolonged  into  the  hilum.  It  is  probable  that  observers, 
in  their  anxiety  to  find  a  solution  for  these  etiological  problems,  have 
been  led  to  draw  their  conclusions  from  well-defined  types,  and  to  neglect 
the  numerous  mixed  forms  which  are  met  with  {vide  Introd.,  vol.  i.  of 
this  System,  p.  xxix).  The  result  is  that  no  sufficient  explanation  has 
been  found  for  the  occurrence  of  these  mixed  tumours. 

It  is  difficult  to  accept  a  different  site  of  origin  for  papillomatous  and 
proliferating  cysts  when  both  may  be  found  in  different  compartments 
of  the  same  tumour.  And  with  regard  to  dermoids,  a  hypothesis  which 
only  accounts  for  the  distinctively  dermoid  portion  of  a  mixed  cystic 
tumour  is  not  a  sufficient  explanation  of  the  origin  of  the  whole  tumour. 

Proliferating  Cysts.  —  According  to  Virchow,  Rokitansky,  and  Rind- 
fleisch,  these  tumours  arise  in  the  ovarian  stroma  by  colloid  degeneration 
of  the  connective-tissue  cells  or  intercellular  substance.  Flihrer,  Klob, 
Doran,  Sutton,  and  I  may  add  almost  all  recent  investigators,  believe 
that  they  arise  from  Graafian  follicles.  Another  view  was  advanced  by 
Klebs  and  Waldeyer,  and  supported  more  recently  by  de  Sinety,  Malassez, 
and  Flaischlen :  these  observers  believe  that  they  arise  from  certain 
tubular  ingrowths  of  the  germ  epithelium  found  in  early  foetal  ovaries, 
and  associated  with  the  development  of  the  Graafian  follicles.  These 
ingrowths  are  known  as  Pfliiger's  tubules.  Such  evidence  as  there  is 
to  hand  certainly  appears  to  favour  the  view  that  these  cysts  arise  in 
the  Graafian  follicles. 

PapiUary  Cysts  and  Tumours.  — Many  observers,  among  whom  may  be 
cited  Olshausen,  Fischel,  and  Doran,  believe  that  papillary  cysts  arise 
from  the  paroophoron,  some  tubules  of  which  have  been  repeatedly 
traced  into  the  hilum  of  the  ovary.  On  the  other  hand,  Marchand  and 
Flaischlen  have  satisfied  themselves  that  these  cysts  also  arise  from 
l^fliiger's  tubules.  The  most  recent  writer  upon  the  subject  is  Dr.  Whit- 
ridge  Williams,  who  has  been  able  to  demonstrate  the  origin  of  papillary 
cysts  from:  (a)  germinal  epitlielium;  (b)  the  Graafian  follicles.  Surface- 
papillomas  he  proves  to  arise  from  the  germ  epithelium.  He  is  not 
satisfied  with  the  evidence  adduced  to  prove  that  papillary  cysts  arise  from 


DISEASES   OF   THE    OVARY  847 

relics  of  the  paroophoron  in  the  liilum  of  the  ovary,  and  believes  that 
their  origin  from  the  epithelium  of  the  Fallopian  tube,  although  possi- 
ble, h^s  yet  to  be  demonstrated.  According  to  the  statistics  of  various 
operators,  the  proportion  of  papillomatous  cystomata  to  glandular  c^'sto- 
mata  is  as  one  to  ten.  When  it  is  remembered  that  mixed  papillary  and 
proliferating  cysts  are  by  no  means  rare,  it  appears  most  probable  that 
they  arise  from  the  same  structures ;  if  so,  the  ditference  of  their  char- 
acters must  depend  upon  some  other  cause. 

Dermoids. — The  etiology  of  these  tumours  is  quite  obscure.  The 
theory  most  generally  accepted  is  that  here,  as  in  other  parts  of  the 
body,  they  are  developed  from  minute  fragments  of  epiblast  included  in 
the  ovary  at  a  very  early  period  of  development. 

It  must  be  remembered,  however,  that  this  ingenious  and  ■\\'idely 
accepted  view  is  by  no  means  a  complete  explanation :  the  occurrence 
of  mixed  forms  of  dermoid  and  proliferating  cysts  points  to  a  follicular 
rather  than  an  intestinal  site  of  origin. 

The  Natural  Progress  of  Ovarian  Tumours.  —  The  majority  of  ovarian 
tumours,  being  proliferating  cysts,  grow  much  more  rapidly,  in  their 
advanced  stages,  than  ovarian  dermoids  and  the  solid  tumours  both 
of  the  uterus  and  ovaries  ;  some  malignant  tumours  excepted.  Owing 
to  their  greater  mobility,  and  to  their  often  unequal  increase  in  size, 
their  position  in  the  abdomen  varies  much  more  than  that  of  the  gravid 
uterus. 

Our  knowledge  of  the  early  stages  of  ovarian  tumours  is  very  small ; 
for  it  is  only  occasionally,  and  almost  by  accident,  that  small  ovarian 
tumours  are  discovered  :  they  may  attain  a  large  size  before  the  patient 
is  led  to  seek  medical  advice.  In  the  early  stages  the  rate  of  growth  is 
probably  quite  slow;  in  the  case  of  dermoids  and  benign  solid  tumours 
it  is  slow  throughout.  Rapid  increase  in  size,  to  such  an  extent  that 
it  can  be  recognised  almost  from  day  to  day,  is  the  result  of  hemorrhage 
into  a  cyst.  This  is  a  complication  almost  equalling  in  importance  the 
occurrence  of  concealed  accidental  haemorrhage  in  the  gravid  uterus. 

If  the  uterus  and  broad  ligaments  are  normal  in  position  the  ovarj', 
enlarged  by  early  cystic  disease,  lies  at  first  in  the  usual  position  on 
the  superior  and  posterior  surface  of  the  broad  ligament  on  one  side  of 
the  middle  line.  As  it  increases  in  bulk  the  tumour  rarely  remains  in  the 
posterior  pelvic  pouch,  but  rises  in  the  direction  of  least  i-esistance,  and 
displacing  the  bowels,  gradually  comes  into  contact  with  the  anterit)r 
abdominal  wall;  then,  if  free  to  move  laterally,  it  tends  to  assume  a 
more  central  position.  The  pedicle  formed  by  the  attachment  of  the 
ovary  to  the  broad  ligament,  while  at  first  anterior  and  inferior  to  the 
tumour,  is  now  as  a  rule  directly  beneath,  and  sometimes  posterior  to  it ; 
the  tumour  lying  more  directly  above  the  uterus.  It  is  supported  by  the 
brim  of  the  pelvis,  causing  little  or  no  discomfort  to  the  patient  and.  if 
the  pedicle  be  long  enough,  no  displacement  of  the  uterus.  Occasion- 
ally the  tumour  becomes  impacted  in  the  pelvis;  either  from  irregularity 
of  enlargement  of  its  component  cysts,  or  from  the  formation  of  adhesions. 


848  SYSTEM   OF  GYNECOLOGY 

Rarely  the  pedicle  may  remain  anterior,  and  the  broad  ligament  is 
then  pulled  up  in  front  of  the  tumour  leading  to  lateral  displacement 
and  fixation  of  the  uterus ;  and  so  to  difficulties  in  diagnosis. 

Again,  in  the  exceptional  cases  in  which  the  tumour  develops  in  the 
liilum  of  the  ovary,  it  may  separate  the  layers  of  peritoneum,  and 
invade  the  broad  ligament  and  the  pelvic  cellular  tissue  continuous 
with  this.  As  a  result  the  uterus  becomes  much  displaced  laterally 
and,  its  mobility  being  restricted,  the  diagnosis  is  obscured. 

Not  infrequently  the  tumour  is  found  to  occupy  the  utero-vesical  pouch 
of  peritoneum,  the  uterus  and  broad  ligaments  lying  retroverted  behind  it. 

When  the  tumour  is  once  fairly  upon  the  pelvic  brim  its  further  en- 
largement usually  leads,  by  pressure  on  the  abdominal  walls  and  viscera, 
to  a  gradually  increasing  prominence  of  the  abdomen  suggestive  of  preg- 
nancy; the  bowels  being  displaced  upwards  and  laterally  as  in  the  case 
of  the  gravid  uterus.  At  this  stage  it  is  usually  recognised  and  removed ; 
but  if  it  continue  to  increase  the  enlargement  of  the  abdomen  becomes 
very  great,  the  diaphragm  is  pushed  upwards,  the  lower  part  of  the 
thorax  becomes  expanded,  and  severe  pressure  symptoms  result.  Cases 
are  recorded  in  which  the  enlargement  of  the  abdomen  was  so  great  that 
the  head  and  limbs  of  the  patient  appeared  to  be  mere  appendages  to 
an  enormous  abdominal  tumour. 

In  such  cases  of  great  abdominal  distension,  the  effects  of  pressure 
on  the  organs  of  respiration,  circulation,  and  digestion  become  so  marked 
that  the  consequent  suffering  and  emaciation  of  the  patient  lead  to  a 
characteristic  facial  expression ;  not  rarely  seen  in  former  days  when, 
owing  to  its  great  mortality,  the  operation  of  ovariotomy  was  usually 
postponed  as  long  as  possible. 

Doran  has  drawn  attention  to  the  frequency  of  dilatation  of  the 
ureters,  with  chronic  interstitial  changes  in  the  kidneys,  found  in  fatal 
cases  after  operation ;  he  believes  that  these  changes  are  the  result  of 
the  pressure  of  the  tumour. 

The  development  of  ovarian  tumours  does  not,  as  a  rule,  interfere 
with  ovulation  and  menstruation  ;  and,  although  both  ovaries  may  be  the 
seat  of  consideraV)le  tumours,  so  long  as  a  portion  of  healthy  ovarian 
tissue  remains,  these  functions  may  be  unaffected.  Mr.  Thornton  has 
recorded  a  case  of  pregnancy  with  bilateral  dermoid  cystic  disease;  the 
relic  of  healthy  ovarian  tissue  being  indicated  by  the  presence  of  a 
corpus  luteum  in  the  wall  of  one  cyst.  But  amenorrhoea  may  occur 
from  great  deterioration  of  the  general  health,  produced  by  the  size  and 
pressure  effects  of  the  tumour,  or  by  its  malignancy. 

In  the  case  of  solid  tumours,  which  are  so  often  bilateral,  amenorrhoea, 
if  present,  may  be  due  to  the  total  destruction  of  Graafian  follicles  which 
usually  occurs  in  these  cases. 

Complications.  —  Cystic  tumours  only  occasionally  cause  hydroperi- 
toneum,  solid  tumours  frequently  do  so;  the  reason  for  this  difference 
is  not  known :  nor  is  it  known  why  solid  tumours  of  the  ovary  should 
do  so  when  similar  tumours  of  the  uterus  do  not. 


DISEASES   OF   THE    OVARY  849 

If  much  fluid  be  found  associated  with  a  cystic  tumour,  it  is  most 
likely  to  be  due,  in  the  absence  of  surface  or  perforating  papilloma  or 
other  extraneous  causes,  to  leakage  from  one  or  more  of  the  cyst  cavities 
into  the  peritoneal  sac.  It  is  frequently  due,  of  course,  to  pressure  of 
the  cyst  upon  the  vena  cava  and  great  abdominal  veins.  In  the  same 
manner  oedema  of  one  or  both  legs  may  occur,  and  in  rare  cases  dis- 
tension of  ureters  and  renal  pelves. 

The  most  frequent  complication  is  that  which  leads  to  the  formation 
of  adhesions  to  adjacent  structures  ;  namely,  to  the  omentum  and  intes- 
tines, oviduct,  uterus,  bladder,  and  abdominal  wall.  Such  adhesions 
may  be  the  result  of  acute  inflammation  of  the  cyst  leading  to  local 
peritonitis,  a  complication  to  be  next  described;  or  they  may  arise 
passively  and  painlessly,  without  any  symptoms  to  alarm  the  patient,  or 
even  to  interfere  with  her  usual  occupation.  A  possible  explanation 
of  their  occurrence  is  that  the  epithelium  covering  the  cyst  wall  in  its 
earlier  stages  may  be  removed  by  friction,  and  a  fibrinous  exudation  would 
then  occur  leading  to  the  formation  of  adhesions  between  the  adjacent 
surfaces.  Such  adhesions  may  be  more  or  less  dense  and  extensive,  or 
merely  thread-like;  sometimes,  especially  when  connected  with  the 
omentum,  they  may  contain  vessels  so  large  as  to  become  an  important 
source  of  blood-supply  to  the  tumour.  Dermoids  appear  to  be  more 
frequently  complicated  by  adhesions  than  are  other  tumours.  Cysts  of  the 
ovary  adherent  to  the  bladder  or  rectum  may  form  communications  Avith 
either  viscus,  and,  in  the  case  of  dermoid  cysts  especially,  with  curious 
results  :  a  lock  of  hair  may  be  found  protruding  from  the  urethra  or  anus ; 
or  bones,  teeth,  and  other  contents  of  these  C3'sts  may  be  evacuated. 

Tubo-ovarian  cysts  usually  arise  in  a  similar  manner ;  they  are  de- 
scribed later  (p.  801).  Adhesions  are  chiefly  important  in  respect  of  the 
difficulties  they  make  for  the  operator;  in  some  cases,  indeed,  the  operator 
has  great  difficulty  in  determining  whether  he  is  dealing  with  the  parietal 
peritoneum,  the  cyst  wall,  or  some  adherent  viscus. 

Acute  Injiammation  of  Cysts. — This  is  usually  a  spontaneous  complica- 
tion. In  the  pre-antiseptic  period  it  was  a  common  result  of  tapping  the 
cyst  for  the  purpose  of  diagnosis  or  treatment ;  and,  together  with  septic 
peritonitis,  was  not  uncommonly  one  of  the  causes  of  the  death  of  the 
patient.  Apart  from  this  it  occurs  most  frequently  in  connection  with 
conditions  which  interfere  Avith  the  vitality  of  the  tumour ;  such  are  acute 
torsion  of  the  pedicle,  injury  by  pressure,  and  strangulation  during  labour. 
Under  such  conditions  pyogenetic  organisms  appear  to  enter  from  the 
intestinal  canal,  nud  lead  to  suppuration.  It  is  probable  also  that  an 
acutely  inHanu^d  Fallopian  tube  becoming  adherent  to  a  cyst  may  infect 
it  without  the  actual  formation  of  a  tubo-ovarian  abscess. 

Torsion  of  the  Pedicle.  — This  complication,  when  acute,  is  one  of  great 
importance ;  for,  unless  recognised  and  dealt  with  by  operation  without 
delay,  the  danger  to  life  is  very  great.  A  slight  degree  of  torsion  (|  of 
a  circle)  is  a  common  occurrence,  and  is  probably  due  to  the  change  of 
position  which  a  small  tumour  undergoes  as  it  rises  from  the  posterior 

3 1 


850  SYSTEM  OF  GYNAECOLOGY 

surface  of  the  broad  ligament  to  a  position  of  greater  mobility  above  the 
pelvic  brim.  This  slight  degree  of  torsion  does  not  produce  symptoms, 
and  is  probably  persistent. 

Under  certain  conditions,  such  as  strain  of  the  abdominal  muscles,  or 
in  connection  with  the  movements  of  the  intestines,  or  from  unequal 
enlargement  of  some  of  the  component  cysts,  this  slight  torsion  becomes 
increased  gradually  or  suddenly,  with  results  which  vary  with  the  sud- 
denness and  degree  of  the  strangulation.  In  the  slowly  produced  cases 
the  circulation  is  gradually  obstructed ;  as  a  result,  the  growth  of  the 
tumour  may  be  arrested.  In  rare  cases  atrophy  of  the  twisted  pedicle 
is  so  complete  that  the  tumour  becomes  more  or  less  separated  from  its 
original  attachment;  its  vitality  may  then  be  maintained  by  a  blood-supply 
obtained  from  the  adherent  viscera,  most  commonly  from  the  omentum. 
If  no  such  adhesions  exist,  the  tumour  lies  free  or  almost  free  in  the  peri- 
toneal cavity,  and  gives  rise  to  considerable  hydroperitoneum.  Acute 
torsion  is  a  far  more  serious  matter ;  the  sudden  interference  to  the  return 
of  blood  from  the  tumour  frequently  leads  to  haemorrhage  into  it,  and 
consequently  to  rapid  enlargement.  The  tumour  also  becomes  very 
tender,  and  the  condition  comes  to  simulate  cases  of  moderately  acute 
latent  accidental  haemorrhage  in  advanced  pregnancy.  I  have  seen  a 
case  in  which,  in  a  young  patient,  torsion  of  the  j)edicle  led  to  severe 
haemorrhage  into  the  cyst ;  as  a  consequence  of  this  accident  it  ruptured 
into  the  peritoneal  cavity,  which  was  filled  with  blood.  The  symp- 
toms were  very  urgent.  The  patient,  however,  made  an  excellent 
recovery. 

In  other  cases  strangulation  of  the  pedicle  interferes  with  the  vitality 
of  the  tumour,  and  allows  it  to  be  rapidly  invaded  by  septic  micro- 
organisms, resulting  in  an  acute  inflammation  of  the  cyst  and  peritoneum 
which  necessitates  immediate  operation. 

Hermann  W.  Freund  has  discussed  the  mechanism  of  torsion  of  the 
pedicle,  and  suggested  that  a  law  may  be  laid  down  that  right-sided 
tumours  rotate  to  the  left,  and  that  left-sided  tumours  rotate  to  the 
right ;  he  admits,  however,  that  there  are  many  exceptions  to  this  law. 
Professor  A.  li.  Simpson  has  also  illustrated  the  same  law  by  three 
cases.  Freund  quotes  ten  cases  ;  in  six  only  was  the  pedicle  twisted,  in 
four  the  rotation  was  right,  and  in  two  left  sided.  Of  the  four  which 
rotated  to  the  right,  two  were  right  tumours,  and  two  left ;  and  of  the 
two  which  rotated  to  the  left,  one  was  a  right,  the  other  a  left  tumour. 
Out  of  sixty-six  cases  of  ovariotomy  at  St.  Bartholomew's  Hospital, 
between  August  l.Sl)2  and  October  1894,  there  were  fifteen  cases  of 
torsion  of  the  pedicle  of  ovarian  cysts,  and  one  of  a  broad  ligament  cyst. 
Of  ten  left-sided  tumours,  six  were  twisted  in  the  opposite  direction  to 
the  movements  of  the  hands  of  a  watch,  that  is,  from  right  to  left;  and 
four  in  the  same  direction,  that  is,  from  left  to  right.  Of  five  right-sided 
tumours  three  wei'e  twisted  from  left  to  right,  and  two  from  right  to 
left.  These  numbers  are  not  large  enough  to  decide  the  question  of 
Freund's  "law";  but  they  suggest  that  the  direction  of  rotation  does 


DISEASES   OF   THE    OVARY  851 

not  present  a  constant  relation  to  the  side  to  which  the  tumour  is 
attached. 

Incarceration  of  Ovarian  Tamonrs  in  the  Pelvis.  —  This  is  a  rare  com- 
plication ;  but  it  is  found  occasionally  in  the  case  of  tumours  which  invade 
the  broad  ligament,  and  which  having  no  pedicle  are  greatly  restricted 
in  their  mobility.  Still  more  rarely  a  pedunculated  ovarian  tumour  may 
become  incarcerated  in  the  retro-uterine  pouch  of  the  pelvic  peritoneum, 
giving  rise  to  retention  of  urine ;  as  in  the  far  less  rare  cases  of  incarcera- 
tion of  uterine  fibroids  or  extra-uterine  gestation  cysts.  In  St.  Bartholo- 
mew's Hospital  Museum  is  a  rare  specimen  (No.  2951c)  of  a  dermoid 
cyst  adherent  to  the  uterus,  and  causing  retention  of  urine.  This  was 
unrelieved,  owing  to  the  common  mistake  of  not  recognising  that  con- 
stant dribbling  of  urine  following  retention  is  a  symptom  of  extreme 
distension  of  the  bladder. 

Rupture  of  Cystic  Tumours.  —  This  occurs  in  three  forms :  (a)  Rupture 
of  a  thin-walled  unilocular  cyst,  leading  to  a  sudden  disappearance  of  the 
tumour,  and  the  presence  of  free  fluid  in  the  peritoneal  cavity.  In  these 
cases  the  cyst  usually  fills  again.  (6)  The  rupture  of  one  or  more  loculi 
of  a  multilocular  cyst,  leading  to  constant  leakage  into  the  peritoneum, 
and  thus  to  the  presence  of  a  cystic  tumour  with  free  fluid,  (c)  The 
perforation  or  rupture  of  a  cyst,  or  parts  of  a  cyst  containing  papillomas, 
followed  by  the  detachment  and  escape  of  particles,  and  the  spreading 
of  the  growth  over  adjacent  parts.  The  rupture  may  occur  spontaneously, 
or  during  a  medical  examination,  or  in  consequence  of  injuries,  such  as 
falls  or  blows.  If  the  contents  of  the  cyst  are  aseptic,  as  is  usually 
the  case,  the  immediate  effects  are  slight.  Unless  litemorrhage  occur 
there  is  little  pain  or  shock,  as  a  rule ;  although  sometimes  these  are 
marked.  The  tumour  of  course  disappears,  and  occasionally  does  not 
reappear.  The  fluid,  if  thin,  is  rapidly  absorbed  by  the  peritoneum,  and 
excreted  by  the  kidneys ;  a  condition  of  polyuria  persisting  for  some 
days.  If  the  fluid  is  viscid  it  accumulates  in  the  peritoneal  cavity,  the 
cyst  contiiuially  leaking  ;  gradually  it  occupies  all  the  peritoneal  spaces 
between  the  bowels,  and  even  the  more  distant  parts  between  the  liver 
and  the  diaphragm,  so  that  it  becomes  very  dilflcult  to  remove  it  entirely 
at  the  operation. 

A  case  of  infection  of  the  peritoneum  with  dermoid  growths  after 
rupture  of  the  primary  tumour  has  already  been  mentioned ;  and  the 
spreading  of  papillomatous  growths  in  this  way  is  well  known.  Such 
secondary  growths  are  benign ;  and  after  removal  of  the  main  tumour, 
although  the  infected  peritoneum  is  very  iniperfectly  dealt  with,  spread- 
ing ceases,  and  the  patient  makes  a  permanent  recovery. 

Pregnane;/  and  Labour  complicated  by  Ovarian  Tumours.  —  Ovarian 
tumours  form  a  very  important  complication  of  pregnancy  and  labour. 
The  difticulty  during  pregnancy  is  in  the  diagnosis,  not  in  the  treatment : 
experience  shows  that  ovarian  tumours  may  be  safely  dealt  with  at  any 
period  of  pregnancy ;  and  as  a  general  principle  should  be  so  dealt  ^\'ith. 

Labour  may  be  complicated  by  the  presence  of  an  ovarian  tumour  in 


852  SyST£J/   OF  GYN.-ECOLOGY 

the  abdomen  or  in  the  pelvis.  In  the  abdomen  tumours  may  be  of  con- 
siderable size  without  doing  much  harm ;  but  if  even  a  small  tumour 
occupy  the  utero-sacral  pouch  of  the  pelvis  it  will  cause  obstruction, 
and  must  be  dealt  with.  ]\Iost  of  these  are  cystic  tumours ;  but  a  case 
of  fibroma  of  the  ovary  has  been  recorded  by  myself  Avhich  during  labour 
simulated  the  head  of  a  second  extra-uterine  foetus. 

Cystic  tumours  have  been  driven  down  by  the  advancing  foetal  head, 
and  have  burst  through  the  posterior  vaginal  wall,  so  that  the  tumour 
has  been  spontaneously  delivered  before  the  foetus. 

Sometimes  it  is  possible,  under  deep  anaesthesia,  to  raise  the  tumour 
above  the  pelvic  brim,  and  so  out  of  the  way ;  especially  during  the 
earlier  stages  of  labour. 

When  the  obstructing  tumour  is  a  thin-walled  cyst,  simple  puncture 
through  the  posterior  vaginal  wall  will  be  the  best  method  of  dealing 
with  it  for  the  time.  When  this  is  not  successful,  owing  to  its  multi- 
locular  character,  or  when  the  tumour  is  solid,  there  can  be  no  doubt 
that  abdominal  section,  followed,  in  certain  cases,  by  the  Caesarean  section 
and  removal  of  the  tumour,  is  preferable  to  dragging  the  foetus  past  the 
obstructing  mass.  When  this  latter  course  is  adopted,  so  much  injury 
is  done  to  the  tumour,  as  a  rule,  that  afterwards  it  becomes  acutely  in- 
flamed, and  the  patient  is  placed  in  a  state  of  very  great  danger. 

Diagnosis.  —  Ovarian  and  Broad  Ligament  Tumours.  —  The  diagnosis 
of  ovarian  tumours  rests  upon  the  recognition  of  their  physical  characters, 
for  there  are  no  symptoms  of  diagnostic  value;  the  abdominal  enlarge- 
ment which  attracts  the  patient's  attention  is  generally  her  only  com- 
plaint. Still  this  very  absence  of  symptoms,  coupled  with  progressive 
enlargement  of  the  abdomen,  is  of  value  in  the  investigation  of  the  case ; 
and  in  the  endeavour  to  set  aside  other  abdominal  diseases.  It  does  not 
require  a  very  large  experience  to  convince  us  that,  as  Matthews  Duncan 
said,  until  the  abdomen  is  opened  and  the  tumour  exposed,  the  diagnosis 
of  such  cases  is  not  one  of  scientific  precision,  but  rather  of  a  great  proba- 
bility ;  amounting,  no  doubt,  in  very  many  cases  to  practical  certainty. 
This  fact,  coupled  with  personal  recollection  of  mistakes,  will  make  the 
physician  cautious  even  in  cases  that  appear  to  be  simple,  and  still  more 
so  when  they  present  unusual  cliaracters.  In  the  large  majority  of 
cases,  so  long  as  the  patient's  health  is  not  seriously  affected  by  this  or 
other  causes,  and  the  uterus  itself  is  healthy,  menstruation  and  ovulation 
continue  unaffected  by  the  disease.  Interference  with  ovulation  is  of 
much  more  frequent  occurrence  in  the  case  of  the  rare  solid  tumours  than 
it  is  in  cystic  tumours.  Too  much  stress  has  been  laid  by  some  authors 
on  the  presence  of  a  tendency  to  amouorrhoea  as  a  symptom  of  ovarian 
cystoma.  It  is  far  more  correct  to  say  that  the  al)sence  of  amenorrhoea 
and  other  menstrual  disorders  is  the  symptom  of  importance.  That  is 
to  say,  that  in  a  woman  having  an  abdominal  tumour  of  pelvic  origin,  if 
the  menstrual  function  remain  normal  it  is  of  diagnostic  value  in  favour  of 
ovarian  tumour;  and  as  a  symptom  it  must  be  considered  as  of  equal  value 
to  the  amenorrhfBa  of  pregnancy  and  the  monorrhagia  of  uterine  fibroids. 


DISEASES    OF   THE    OVARY  853 

Of  the  last  118  consecutive  cases  operated  on  in  ''Martha"  ward  at 
St.  Bartholomew's  Hospital  up  to  March  1895  —  20  cases  were  in  patients 
either  before  puberty  or  after  the  menopause.  Of  the  remaining  98  — 
in  73  menstruation  was  normal ;  in  7  there  was  amenorrhoea  for  short 
periods — 3-12  months ;  in  3  the  menstrual  flow  was  lessened  in  quantity : 
in  3  menorrhagia  was  present ;  in  4  menstruation  was  increased  in  quan- 
tity, but  the  health  was  not  thereby  affected;  in  8  menstruation  was 
quite  irregular  as  regards  both  time  and  quantity.  These  figures  show 
that  in  about  75  per  cent  of  cases  of  ovarian  tumour  menstruation  con- 
tinues unaltered  during  the  twelve  months  preceding  the  diagnosis  of 
the  tumour ;  and  that  in  the  remaining  cases  increased  loss  is  nearly  as 
frequent  as  diminished  loss.  But  in  these  cases  of  altered  menstrua- 
tion the  possibility  of  a  uterine  cause  must  be  borne  in  mind  before  the 
disturbance  is  assigned  to  the  ovarian  tumour. 

Pain  is  an  unusual  syniptom  in  cases  uncomplicated  by  impaction, 
inflammation,  or  strangulation;  and  the  pressure  effects  are  usually  not 
attended  by  much  discomfort  until  the  tumour  has  attained  a  considera- 
ble size.  In  rare  cases  the  pressure  appears  to  be  the  immediate  cause 
of  procidentia  uteri,  even  in  nulliparous  women.  I  have  seen  two  such 
cases  in  neither  of  which  was  the  tumour  impacted. 

Matthews  Duncan,  in  his  Clinical  Lectures,  says  with  regard  to  the 
diagnosis  of  ovarian  cystoma:  "You  get  no  aid  from  symptoms.  Fre- 
quently there  are  and  have  been  no  symptoms ;  the  case  comes  before 
you  solely  on  account  of  size ;  or  you  may  accidentally  discover  the 
tumour.  Sometimes  there  are  symptoms  which  may  be  described  as 
resembling  those  of  advancing  pregnancy;  only  instead  of  the  mam- 
mary and  clavicular  fat  increasing  as  they  generally  do  in  pregnancy, 
you  have  them  generally  diminishing.  Sometimes  you  have  disturb- 
ance of  menstruation.  Sometimes  you  have  a  history  of  severe  pain  in 
the  womb,  or  in  one  or  the  other  ovarian  region.  Sometimes  you  are 
told  the  swelling  began  on  one  side.  But  all  these  indications  vary 
much,  and  however  they  may  be  combined  they  form  no  basis  for  a 
diagnosis." 

The  first  stage  in  the  diagnosis  of  ovarian  tumour  is  obviously  the 
recognition  of  an  abdominal  or  pelvic  tumour.  The  second  is  the  identi- 
fication of  the  tumour  as  ovarian,  partly  by  the  recognition  of  its  physical 
characters,  partly  by  exclusion  of  other  kinds  of  tumour.  Both  of  these 
stages  present  difliculties,  sometimes  so  great  that  nothing  short  of  an 
exploratory  opening  of  the  abdomen  is  sufticient  to  determine  the  diag- 
nosis :  and  there  are  cases  of  such  obscurity  that  even  this  operation, 
in  the  hands  of  an  experienced  operator,  followed  by  more  or  less  com- 
plete evacuation  of  the  contents  of  some  cavity,  may  prove  insufficient 
to  determine  the  exact  nature  and  origin  of  the  tumour. 

In  the  first  place,  let  it  be  certain  that  the  bladder  is  empty,  using 
the  catheter  if  there  be  any  doubt  on  this  point.  It  would  be  easy  to 
quote  examples  of  mistakes  made,  not  by  beginners  only,  from  neglect 
of  this  simple  precaution.     Almost  equally  important  is  the  clearing 


854  SVSTEJf  OF  GYNECOLOGY 

out  of  the  bowels ;  for  fascal  masses  are  not  infrequently  mistaken  for 
abdominal  tumours.  Next,  and  of  first-rate  importance,  let  it  be  alwa3^s 
assumed  that  a  woman,  who  is  of  the  child-bearing  age,  and  whose  men- 
struation has  been  absent  for  a  period  of  one  to  twelve  months,  is  pregnant 
until  absolute  proof  to  the  contrary  be  obtained.  Mistakes  in  connection 
with  pregnancy  are  the  most  common  and  the  least  excusable  of  any. 
How  often  do  we  meet  with  cases  in  which  a  simple  normal  uncompli- 
cated pregnane}^  is  diagnosed  to  be  an  ovarian  cyst ;  and  how  often  is  a 
woman  or  girl  suspected  of  pregnancy,  sometimes  even  accused  of  it, 
when  her  only  misfortune  is  an  ovarian  tumour ! 

The  diagnosis  of  pregnancy,  intra-  or  extra-uterine,  when  the  foetus 
is  dead,  of  pregnancy  with  hydramnion  or  complicated  with  ovarian  or 
other  tumours  of  considerable  size,  is  often  difficult  enough ;  but  that 
of  normal  pregnancy,  advanced  to  such  a  size  as  to  form  an  abdominal 
tumour,  is  simple  if  the  examination  be  systematic.  This  is  not  the 
place  to  go  fully  into  the  question  of  the  diagnosis  of  pregnancy ;  but 
it  may  be  mentioned  that  the  easiest  way  of  diagnosing  this  condition 
beyond  the  fifth  month  (that  is,  the  fundus  above  the  navel)  is  by  pal- 
pation of  the  abdomen,  when  the  hand  may  recognise  parts  of  the  foitus 
floating  in  fluid,  and  some  of  them  may  present  spontaneous  movements. 
Next,  in  every  case  of  obscurity,  let  the  patient  be  put  under  an 
anaesthetic;  and  when  muscular  relaxation  is  complete,  repeat  the 
examination  of  the  abdomen  and  pelvis.  The  general  condition  of  the 
abdomen,  fluctuation,  and  the  area,  site,  and  limits  of  the  supposed 
tumour  become  far  clearer  when  the  abdomen  is  well  relaxed;  hence  the 
aid  of  an  anaesthetic  is  often  invaluable. 

Recognition  of  Abdominal  Tumour. — This  involves  the  recollection  and 
the  exclusion  of  conditions  which  simulate  abdominal  tumours :  namely, 
enlargement  of  the  abdomen  by  accumulation  of  fat  in  its  walls  and 
within  it ;  distension  by  flatulent  bowel  and  by  fsecal  masses ;  ascites ; 
and  masses  of  bowel  matted  together  by  adhesions,  with  or  without  much 
fluid  efl'usion.  Of  these,  certain  cases  of  localised  hydroperitoneum  and 
cases  of  chronic  peritonitis  are  apt  to  give  rise  to  the  greatest  difficulties 
of  diagnosis. 

An  ovarian  tumour  has  usually  a  well-defined  outline  above  and  at 
the  sides  ;  it  is  often  irregular,  not  rarely  nearly  spherical ;  usually  there 
is  a  distinct  feeling  of  fluid  within  it,  with  well-marked  fluctuation  in 
parts,  if  not  in  the  whole  mass. 

The  presence  of  fluc^tnation  in  all  directions,  and  over  the  whole  area 
of  an  abdominal  tumour,  jjroves  the  continuity  of  the  fluid  and  the  ])rac- 
tically  unilocular  nature  of  the  cyst;  but  this  may  be  closely  simulated 
in  some  cases  of  solid  tumour  in  front  of  which  lies  a  layer  of  free  fluid. 

Hard  masses  felt  in  an  otherwise  cystic  tumour  usually  indicate 
secondary  cysts,  which  when  small  are  usually  very  tense  and  feel  solid ; 
they  have  no  tendency  to  ballottement,  and  do  not  present  spontaneous 
movements,  as  do  parts  of  a  foitus  in  utero.  There  is  dulness  on  per- 
cussion over  its  wliole  surface,  except  perhaps  at  the  margins  where 


DISEASES   OF   THE    OVARY  85: 


bowel  distended  with  gas  may  overlap  it,  or  by  contact  give  a  false 
impression  of  resonance. 

JSTo  pain  is  given  l)y  palpation  unless  strangulation  or  inflammation 
of  the  tumour,  or  considerable  hsemorrhage  into  it,  have  occurred.  An 
ovarian  tumour  is  usually  dumb,  no  souffle  being  audible  as  it  frequently 
is  in  all  kinds  of  uterine  tumour;  but  pulsation  sounds  commum- 
cated  from  the  great  abdominal  vessels  may  be  heard  and  are  of  no 
importance. 

The  recognition  of  these  features  will  enable  us  to  exclude  all  the 
ordinary  conditions  simulating  abdominal  tumours.  There  is  no  defined 
tumour,  dull  on  percussion,  produced  by  accumulation  of  fat,  or  by 
distended  flatulent  bowels ;  whilst  faecal  masses  are  more  likely  to  be 
overlooked  than  to  be  mistaken  for  ovarian  tumours :  I  have  already  re- 
ferred to  the  paramount  necessity  of  clearing  the  bowels  and  emptying 
the  bladder  before  attempting  to  make  a  diagnosis. 

Hudroperitoneum  (Ascites).  —  It  is  only  under  exceptional  circum- 
stances that  a  passive  hydroperitoneum  gives  rise  to  difficulty  in  diag- 
nosis in  relation  to  ovarian  tumours.  Hydroperitoneum  may  be  present 
with  any  form  of  abdominal  tumour ;  or  if  one  or  more  parts  of  a  cystic 
tumour  having  burst  continue  to  leak  into  the  peritoneal  cavity,  a  con- 
dition of  tumour  with  free  fluid  may  be  produced.  In  such  cases  the 
tumour  Avill  usually  be  felt,  and  the  presence  of  free  fluid  ascertained 
with  equal  certainty. 

But  the  most  puzzling  and  unexpected  cases  are  those  in  which  a 
passive  serous  effusion  takes  place,  perhaps  to  the  extent  of  several  pints ; 
and  the  fluid,  instead  of  sinking  to  the  most  dependent  parts,  is  con- 
fined to  the  centre  of  the  abdomen,  in  a  kind  of  sac  formed  by  the 
coils  of  intestine  tightly  pressed  together  or  slightly  adherent.  The 
physical  characters  of  such  a  collection  are  not  distinguishable  from  those 
of  a  thin-walled  unilocular  cyst.  Two  such  cases  occurred  in  succession 
in  my  own  practice,  and  both  Avere  mistaken  for  ovarian  cysts. 

Collections  of  fluid  in  the  peritoneal  cavity  in  connection  with  chronic 
tubercular  peritonitis,  are  frequently  met  with ;  but  as  a  rule  a  "  tumour  " 
thus  formed  will  be  resonant  on  percussion  over  a  large  part  of  its  area, 
and  will  be  accompanied  by  other  signs  of  evident  illness ;  the  tempera- 
ture will  usually  be  found  distinctly  raised  at  night  —  a  symptom  of  the 
highest  importance. 

The  last  class  of  false  abdominal  tumours  are  those  formed  from 
matted  coils  of  intestine  and  omentum,  with  more  or  less  fluid  in  the 
interstices,  whether  serum  or  pus.  Such  masses  are  produced  in  connec- 
tion with  inflammations  of  the  vermiform  appendix,  or  of  the  ovaries 
and  oviducts  ;  and  these,  from  their  close  proximity  and  frequent  adhe- 
sion to  the  uterus,  are  liable  to  be  mistaken  for  uterine  fibroids. 

Dkirpiosis  of  Pelvic  Tumours.  — To  recognise  the  presence  of  a  pelvic 
tumour,  and  still  more  to  be  able  to  identify  its  nature,  is  a  far  more 
difficult  nuitter  than  in  the  case  of  most  abdominal  tumours.  It  requires 
not  only  an  intimate  knowledge  of  the  subject,  but  a  greater  experience 


856  SYSTEM   OF  GYNAECOLOGY 

in  the  practical  application  of  that  knowledge  than  most  practitioners 
are  able  to  obtain.  We  have  here  first  to  deal  with  the  recognition  of 
a  tumour. 

A  pelvic  ■  tumour  from  simple  anatomical  reasons  is  most  likely  to 
occupy  that  part  of  the  pelvic  cavity  which  lies  above  and  behind  the 
uterus  and  broad  ligaments.  This  space,  in  health,  is  occupied  by  coils 
of  small  intestine,  which  are  very  easily  displaced  from  it ;  and  it  varies 
in  size  with  the  varying  distension  of  the  bladder  and  rectum.  Normally 
the  utero-vesical  pouch  is  merely  a  linear  cavity,  the  uterus  and  broad 
ligaments  resting  directly  on  the  bladder.  This  linear  cavity  is  at  once 
opened  up  and  admits  coils  of  small  intestine,  Avhen  the  uterus  and 
broad  ligaments  are  retroverted ;  and,  under  such  conditions,  is  of  course 
most  open  when  the  bladder  is  empty.  A  pelvic  tumour  can  only  be 
recognised  in  either  of  these  cavities  by  a  bimanual  examination ;  and 
the  emptying  of  bladder  and  rectum,  and  the  use  of  an  anaesthetic,  are 
of  the  greatest  importance  in  this  examination,  as  in  the  case  of  ab- 
dominal tumours. 

A  tumour  may  be  so  small  as  not  to  lead  to  any  appreciable  displace- 
ment of  the  uterus ;  such  are  the  rare  tumours  of  the  round  ligaments 
of  the  uterus,  the  common  small  enlargement  of  the  ovaries  and  tubes, 
and  small  uterine  fibroids.  But  as  a  rule  the  tumour,  according  to  its 
position  and  size,  will  be  found  to  displace  the  uterus  more  or  less  to  the 
opposite  side  if  lateral  to  the  uterus  ;  forwards  if  behind  it ;  backwards 
if  in  front  of  it. 

The  first  suspicion  of  the  presence  of  a  pelvic  tumour  usually  arises 
during  a  vaginal  examination.  The  cervix  is  first  identified  either  in  a 
nearly  normal  position  or  displaced  laterally,  anteriorly,  posteriorly, 
upwards  or  downwards ;  and  careful  palpation  reveals  a  convex  swelling 
behind,  in  front,  or  on  one  or  on  both  sides  of  it.  The  next  stage  is  to 
ascertain  that  the  convex  swelling  is  part  of  the  surface  of  a  more  or  less 
spherical  tumour,  not  something  simulating  one.  The  conditions  most 
likely  to  simulate  a  tumour  are —  (i.)  the  body  of  the  uterus  felt  as  it 
normally  is  through  the  anterior  fornix ;  or  felt  more  readily  than  nor- 
mally because  auteflexed  or  because  of  an  increase  of  its  normal  ante- 
version;  or  felt  on  one  side  of  the  cervix  from  lateral  displacement;  or 
through  the  posterior  fornix  from  retroversion  or  retroflexion :  (ii.)  the 
bladder  more  or  less  distended,  or  the  rectum  loaded  with  faeces:  (iii.) 
some  adhesions  intra-  or  extraperitoneal.  The  diagnosis  of  the  second 
states  is  so  easily  determined  by  the  use  of  the  catheter,  and  by  digital 
examination  of  the  rectum,  that  it  is  not  necessary  to  allude  to  it  further ; 
Ijut  adhesions,  the  result  of  perimetritis,  or  parametritis,  require  care- 
ful examination.  In  the  first  place,  simple  adhesions  usually  draw  the 
uterus  to  the  affected  side,  and  by  bimanual  examination  are  found  to 
have  little  thickness;  the  two  hands  may  meet,  and  the  absence  of  a 
"tumour"  is  then  clear.  If  there  be  much  effusion  of  ])us,  blood,  or 
serum,  either  into  the  cellular  tissue  or  peritoneum,  a  definite  tumour 
is  formed  and  the  uterus  is  displaced  ironi  its  normal  position.     If,  by  a 


D/SEASES   OF   THE    OVARY  857 

liiinaniial  examination,  the  abdominal  hand  finds  a  convex  surface  project- 
ing into  or  above  the  pelvic  inlet,  and  corresponding  with  that  discovered 
by  the  finger  in  the  vagina,  the  presence  of  a  "  tumour"  is  then  clear;  and 
we  proceed  to  endeavour  to  ascertain  its  nature,  and  in  the  first  place  to 
determine  that  it  is  not  the  body  of  the  uterus  enlarged  by  pregnancy, 
or  by  such  diseases  as  produce  uniform  increase  in  size  —  such  as  certain 
fibroids,  cancer  of  the  body,  pyometra,  hsematometra,  and  hydrometra. 

Here,  as  in  the  case  of  abdominal  tumours,  to  set  aside  pregnancy 
is  of  the  first  importance,  a  task  by  no  means  always  easy  even  to  the 
experienced  physician ;  and  it  is  not  rare  to  find  pregnancy  at  any  stage 
complicated  by  the  presence  of  a  tumour. 

The  diagnosis  of  the  pathological  enlargements  of  the  body  of  the 
uterus  is  given  elsewhere,  the  difficult  bimanual  examination  being  of 
the  greatest  im.portance. 

If  pregnancy  is  certainly  set  aside,  the  uterine  sound  passed  up  to 
the  fundus  is  of  the  greatest  value  ;  for  it  not  only  determines  the  length 
of  the  uterine  cavity,  a  detail  of  great  value  in  distinguishing  uterine 
from  non-uterine  pelvic  and  abdominal  tumours,  but  it  identifies  the 
relative  positions  of  tumours  lying  close  to  it  in  cases  in  which  a 
bimanual  examination  has  failed  to  do  so.  The  difficulties  which  are 
met  with  in  passing  the  sound  to  the  fundus,  however,  lead  sometimes 
to  mistakes  in  both  these  particulars,  and  to  incorrect  inferences. 

Having  now  excluded  or  recognised  enlargement  of  the  body  of  the 
uterus,  and  determined  that  there  is  a  tumour  adjacent  to  it,  and  what 
their  relative  positions  are,  we  proceed  to  considei-,  one  by  one,  the 
different  forms  of  tumour  that  may  be  present. 

The  consideration  of  such  tumours  shows  how  necessary  it  is  to  have 
a  wide  knowledge  of  the  diseases  themselves,  and  of  their  symptoms  and 
physical  characters,  as  well  as  a  large  experience  in  practical  diagnosis, 
to  enable  the  practitioner  to  arrive  at  an  accurate  conclusion  ;  and  every 
one  knows  hoAv  often  the  diagnosis,  even  by  men  of  large  experience,  is 
imperfect,  or  indeed  sometimes  quite  mistaken. 

Before  proceeding  further  it  Avill  be  well  to  return  to  abdominal 
tumours  that  Ave  may  make  a  preliminary  selection  of  them,  as  both 
pelvic  and  abdominal  tumours  have  many  points  in  common;  and  the 
differential  diagnosis,  Avhen  once  the  tumour  is  ascertained  to  have  a 
pelvic  origin,  proceeds  on  almost  identical  lines.  Also  abdominal 
tumours  can  often  be  felt  on  vaginal  examination  to  lie  partially  Avithin 
the  pelvis;  e\^en  sometimes  Avhen  they  arise  from  organs  so  distant  as 
the  kidneys  and  spleen.  We  must,  therefore,  bear  in  mind  that  Avhile 
tumours  contained  in  the  pehas  are  almost  invariably  of  pelvic  origin, 
abdominal  tumours  Avhich  lie  entirely  above  the  brim  of  the  pelvis  may 
have  originated  either  in  the  pelvic  or  in  the  abdominal  organs;  and  that 
tumours  that  lie  partl_y  in  the  abdomen  and  partly  in  the  pelvis,  Avhile 
usually  of  pelvic  origin,  may  have  arisen  ])rimarily  in  an  abdominal 
organ,  and  have  descended  later  into  the  pelvis. 

Diagnosis  of  the  Site  of  Origin  of  an  Abdominal  Tuniou):  —  It  is  not  nee- 


S5S  SYSTEM  OF  GYi\L€.COLOGY 

essary  here  to  discuss  all  possible  sites  for  every  variety  of  abdominal 
tiuiiour.  We  begin  with  the  assumption  that  the  tumour  before  us  is  so 
situated  in  the  abdominal  cavity  that  a  pelvic  connection  is  not  altogether 
improbable ;"  thus  we  exclude  at  once  such  tumours  as  those  of  the  gall- 
bladder and  pylorus.  Now  such  a  tumour  may  arise  in  the  pelvic,  renal, 
splenic,  hepatic,  and  central  (mesenteric  and  omental)  regions.  A 
tumour  of  pelvic  origin  can  be  traced  down  to  the  pelvic  brim,  as  the 
physician  stands  by  the  side  of  the  patient  and  looks  towards  her  feet, 
with  his  hands  placed  on  her  abdomen  and  his  fingers  directed  down- 
wards to  the  pelvis ;  there  will  be  no  area  of  resonance  between  the 
prominent  part  of  the  abdominal  tumour  and  the  pelvic  brim,  because 
the  tumour,  as  it  arose  out  of  the  pelvis,  will  have  displaced  the  intes- 
tine in  much  the  same  way  as  a  gravid  uterus  does,  and  will  lie  in  con- 
tact with  the  abdominal  wall.  A  small  tumour  of  pelvic  origin  lying 
above  the  pelvic  brim  is  usually  very  freely  movable,  and  may  therefore 
be  found  sometimes  on  one  side,  at  other  times  on  the  other ;  but  if  it 
be  found  constantly  on  one  side,  this  will  indicate  Avith  great  probability 
the  side  from  which  it  sprang. 

Large  tumours,  having  to  accommodate  themselves  with  greater 
difficulty  to  the  abdominal  cavity,  are  more  centrally  placed,  and  their 
mobility  is  much  more  restricted. 

Many  tumours  arising  from  the  kidneys  are  easily  identified  as  to 
their  origin.  A  renal  tumour  is  almost  confined  to  one-half  of  the 
abdominal  cavity,  and  it  can  be  traced  by  bimanual  palpation  (one  hand 
being  on  the  abdominal  surface  of  the  tumour,  the  other  on  the  loin) 
right  into  the  region  of  the  kidney. 

The  only  tumours  of  the  liver  likely  to  be  mistaken  for  ovarian  are 
hydatids.  They  are  notoriously  deceptive ;  but  as  a  rule  their  connec- 
tion with  the  liver  can  be  traced,  and  an  area  of  resonance  between  the 
tumour  and  the  pelvis  can  be  detected. 

A  large  fluctuating  hydronephrosis,  extending  well  across  the  middle 
line  of  the  abdonjen  and  so  far  down  into  the  cavity  of  the  pelvis  that  it 
can  be  reached  by  a  vaginal  examination,  may  very  easily  be  mistaken 
for  an  ovarian  cyst. 

The  spleen  may  become  dislocated  and  greatly  enlarged,  and  sinking 
down  to  the  pelvis  be  mistaken  for  an  ovarian  tumour.  Mr.  Meredith 
operated  on  such  a  case,  which  he  and  the  writer  believed  to  be  a  solid 
ovarian  tumour.  It  occupied  the  utero-vesical  pouch,  where  it  was  easily 
recognised ;  and  it  rose  nearly  to  the  navel.  On  opening  the  abdomen 
a  black  mass  was  exposed,  which  proved  to  be  the  spleen.  It  was  left 
untouched  in  this  position,  the  patient  being  in  excellent  health.  The 
cause  of  the  dishication  appeared  to  have  been  a  violent  fall  from  a  dog- 
cart. 

Tumours  arising  in  the  central  abdominal  regions  are  often  very 
puzzling ;  the  presence  of  a  well-defined  area  of  resonant  bowel  between 
thein  and  the  pelvis,  and  the  absence  of  any  definite  connection  with  the 
pelvis,  though  not  sufficient  for  diagnosis,  is  sufficient  to  distinguish 


DISEASES   OF   THE    OVARY  859 

them,  with  rare  exceptions,  from  ovarian  tumours.  It  must  be  borne  in 
mind,  however,  that  in  exceptional  cases  a  tumour  of  pelvic  origin  may 
lose  its  pelvic  attachment,  and  be  fed  by  the  blood-vessels  of  its  omental 
and  other  adhesions;  or  may  have  such  a  long  pedicle  that  it  becomes 
entirely  abdominal  in  position. 

Diagnosis  of  Ovarian  and  Broad  Ligament  Tumours  from  other  Pelvic 
and  Abdominal  Tumours.  —  It  has  already  been  pointed  out  that  the 
diagnosis  of  ovarian  and  broad  ligament  tumours  is  made  by  a  process  of 
exclusion  of  other  forms  of  tumour,  as  well  as  by  the  recognition  of  the 
physical  characters  of  the  tumour  under  observation ;  characters  which 
are  not  always  so  distinctive  as  to  enable  us  to  do  more  than  arrive  at 
an  opinion  of  probability,  but  not  of  certainty :  and  it  not  infrequently 
happens  that  the  complete  diagnosis  is  not  made  until  the  tumour  has 
been  exposed  to  sight  and  touch  by  an  exploratory  operation.  It  is 
obvious  that  under  these  circumstances  it  is  not  only  necessary  to  know 
the  varieties,  the  symptoms,  and  the  physical  characters  of  ovarian  and 
broad  ligament  tumours,  but  that  it  is  also  of  no  less  importance  to  know 
the  varieties,  the  symptoms,  and  the  physical  characters  of  all  tumours 
Avhich  may  occupy  the  same  region,  or  be  otherwise  mistaken  for  them. 
It  is  not  desirable  within  the  limits  of  this  article  to  enter  on  this  part 
of  the  subject,  but  I  will  refer  for  the  last  time  to  the  conditions  which 
too  frequently  lead  to  easily  preventable  mistakes  in  diagnosis.  Of  these 
the  most  common  are  a  normal  pregnancy,  a  distended  bladder,  flatulent 
distension  of  the  bowels,  a  fat  abdominal  wall,  and,  less  frequently, 
simple  ascites.  Such  mistakes  are  the  result  of  ignorance  of  first 
principles,  or  of  carelessness  in  examination ;  they  are  not  to  be  prevented 
lay  other  means  than  knowledge,  due  care,  and  systematic  examination. 
Direct  Recognition  of  the  Physical  Characters  of  Uncomplicated  Ocarian 
and  Broad  Ligament  Tumours.  —  The  large  majority  of  all  these  tumours 
are  cystic.  In  the  rare  cases  of  solid  ovarian  tumours  the  diagnosis  prac- 
tically lies  between  them  and  uterine  fibroids,  either  sessile  or  peduncu- 
lated, projecting  from  the  peritoneal  surface  of  the  uterus ;  these  are 
common  enough.  The  direct  diagnosis  of  the  presence  or  absence  of 
uterine  fibroids  by  bimanual  examination  is  not  usually  diflicult.  If 
hydroperitoneum  he  found  complicating  a  solid  tumour  of  pelvic  origin 
the  tumour  may  be  assumed  to  be  ovarian. 

Cystic  ovarian  or  broad  ligament  tumours,  when  uncomplicated  by 
adhesions  or  impaction,  are  easily  recognised  by  their  well-defined 
spherical  shape  and  obvious  elasticity ;  but  they  have  to  be  distinguished 
from  cystic  dilatation  of  the  oviducts,  and  this  is  frequently  not  by  any 
means  easy,  unless  the  ovary  on  the  same  side  can  be  defined  by  rectal 
examination  (the  uterus,  if  necessary,  being  drawn  down  with  an  appro- 
priate instrument).  The  close  proximity  of  the  two  organs  and  the  great 
similarity  in  shape  and  other  characters  of  the  cysts  formed  in  them, 
make  this  differential  diagnosis  often  \incertain.  The  im]iortance  of  it 
is,  however,  of  the  highest  degree  if  extra-uterine  gestation  be  suspected; 
for  though  the  possibilit}'  of  a  primary  ovarian  pregnancy  cannot  be 


86o  SYSTEM  OF  GYNECOLOGY 

denied,  experience  amply  shows  that  if  the  tumour  can  be  proved  to 
be  ovarian,  it  may  safely  be  assumed  not  to  be  the  seat  of  a  gestation 
sac.  "Cysts  invading  the  broad  ligaments,  or  originating  in  them,  are 
more  obviously  lateral,  and  displace  the  uterus  as  they  increase  in  size ; 
they  are  also  less  freely  movable,  and  not  rarely,  as  they  grow,  they  in- 
sinuate themselves  beneath  the  peritoneum,  beyond  the  limits  of  the  broad 
ligaments  in  the  pelvic  and  abdominal  cavities.  The  essential  points,  then, 
in  the  diagnosis  of  a  pelvic  ovarian  tumour  are  the  discovery  by  bimanual 
examination  of  a  spherical  cystic  tumour ;  or,  much  more  rarely,  of  a 
solid  one,  which,  although  found  to  lie  in  close  relation  to  the  uterus,  is 
ascertained  not  to  be  uterine.  It  is,  of  course,  in  cases  where  the  tumour 
and  the  uterus  are  closely  pressed  together,  or  are  adherent,  that  mistakes 
are  so  easily  made :  but  the  absence  of  menorrhagia  and  of  lengthening 
of  the  uterine  cavity  should  put  us  on  our  guard ;  and  the  advantage 
of  an  examination  under  an  anaesthetic,  which  completely  relaxes  the 
muscles,  is  very  great.  After  consideration  of  the  preceding  details, 
it  will  be  seen  that  Matthews  Duncan's  teaching  fairly  represents  the 
difficulties  of  diagnosis  :  — 

"  I  have  said  it  is  a  nearly  safe  rude  guess  that  you  have  an  ovarian 
dropsy  when  you  find  a  quickly  grown  cystic-feeling  tumour  in  the  belly 
of  a  woman,  and  this  rude  diagnosis  is  nearly  safe  because  of  the  com- 
parative frequency  of  ovarian  dropsy  as  the  cause  of  such  tumours.  .  .  . 
Every  case  demands  careful  investigation,  for  a  good  diagnosis  is  diffi- 
cult, or,  in  other  words,  errors  are  frequent." 

Diagnosis  of  Strangulation  of  the  Pedicle. — The  symptoms  of  this  com- 
plication vary  as  the  arrest  of  the  circulation  in  the  pedicle  is  sudden  or 
gradual ;  complete  or  incomplete. 

In  the  acute  cases  there  is  sudden  and  severe  pain  in  the  region  of 
the  pedicle,  often  accompanied  by  faintness,  vomiting,  and  collapse. 
The  abdomen  is  tender,  and  becomes  much  more  so,  and  is  distended  by 
tympanitic  bowel  as  well  as  by  the  tumour.  Such  symptoms  occurring  in 
a  woman  known  to  have  a  tumour  in  the  pelvis  or  abdomen  are  sufficient 
indication  both  for  diagnosis  and  treatment;  and  the  latter  should  be 
removal  without  delay.  To  wait  for  the  subsidence  of  the  symptoms  of 
peritonitis  is  usually  to  wait  until  it  is  too  late.  Day  by  day,  in  such  a 
case,  the  symptoms  will  be  getting  more  grave  ;  and  careful  observation 
of  the  tumour  will  often  lead  to  the  recognition  of  an  unmistakable 
increase  in  size  (distinguishable  from  conditions  simulating  this,  such  as 
adhesions  of  coils  of  intestine  and  inflammatory  exudation  round  it). 
►Such  enlargement,  noticeable  from  one  day  to  another,  is  the  result 
usually  of  hsemorrhage  into  the  cyst,  or  sometimes  of  the  rapid  formation 
of  pus  in  it;  the  differential  diagnosis  Ijetween  the  two  is  not  at  all  easy, 
but- it  is  of  no  real  importance,  as  the  troatmont  is  the  same  in  both 
cases  —  immediate  removal. 

A  temperature  constantly  below  the  normal  is  in  favour  of  haemor- 
rhage ;  inflammation  of  the  tumour,  which  usually  results  from  acute 
strangulation,  is  attended  by  some  degree  of  fever. 


DISEASES   OF   THE    OVARY  86 1 

The  success  which  follows  operative  treatment  in  such  cases,  when 
correctly  diagnosed,  marks  one  of  the  great  advances  in  abdominal  sur- 
gery in  the  last  few  years.  In  less  acute  cases  the  symptoms  arise  more 
gradually  ;  and  there  is  not  the  imperative  need  for  immediate  removal : 
yet  removal  without  undue  delay  is  the  best  treatment,  for  adhesions, 
when  recent,  can  be  separated  without  difficulty  ;  but  when  they  become 
fibrous  and  tough  great  difficulties  may  be  incurred  in  the  separation,  and 
great  injury  may  be  done  to  important  viscera,  especially  to  the  intestines, 
which  may  lead  to  serious  complications  after  the  patient's  recovery. 

Adhesions  of  the  omentum,  even  when  extensive,  are  surgically  of 
little  importance.  A  curious  condition  of  varicose  vessels  in  the 
omentum  is  sometimes  met  with  resembling  a  bundle  of  worms,  lying 
immediately  beneath  the  abdominal  wall,  on  the  surface  of  the  tumour. 

IxFLAMMATiox  OF  THE  OvARiES.  — It  is  ucccssary  to  bear  in  mind 
that  inflammation  of  the  ovaries  is  intimately  associated  Avith  and  usually 
forms  one  part  of  a  widely  extended  inflammatory  process  involving  the 
uterus,  the  oviducts,  and  the  pelvic  peritoneum  and  cellular  tissue  ;  and 
that  to  describe  apart  the  inflammation  of  any  one  of  these  structures  is 
likely  to  lead  to  narrow  and  erroneous  views,  not  in  pathology  only  but 
also  in  diagnosis  and  treatment. 

Inflammation  of  the  ovaries  may  fairly  be  described  as  occurring 
in  two  forms,  which  are  frequently  though  not  necessarily  combined; 
namely,  inflammation  of  the  surface  (perioophoritis),  and  inflammation 
of  the  organ  itself  (oophoritis). 

Perioophoritis,  resulting  in  adhesions  to  adjacent  parts,  is  commonly 
met  with.  It  is  a  more  or  less  important  part  of  that  disease  —  great  in 
importance  and  frequency,  though  often  slight  in  severity  —  which  is 
known  as  perimetritis  (that  is,  the  pelvic  peritonitis  of  women). 

The  adhesions  may  be  mere  threads  uniting  the  ovary  to  the  omentum 
or  other  adjacent  parts ;  or  a  glueing  of  part  of  its  surface  to  the  mouth 
of  the  oviduct;  or  they  may  be  so  extensive  as  to  lead  to  some  difficulty 
in  finding  and  disembedding  the  ovary  in  the  course  of  an  operation  or 
post-mortem  examination.  Perioophoritis  may  arise  as  an  extension  of 
oophoritis,  but  this  is  probably  not  the  most  frequent  course :  it  is  more 
commonly  part  of  a  perimetritis  arising  by  infection  of  the  pelvic  peri- 
toneum through  the  open  mouth  of  the  oviduct,  or  through  lymph 
channels  or  wounds  communicating  with  the  peritoneal  sac ;  or  again, 
the  result  of  an  effusion  of  blood  into  the  peritoneal  cavity  (ha^matocele). 

In  some  cases  the  disease  ma}^  not  be  of  pelvic  origin,  but  only  part 
of  a  general  peritonitis  of  septic  or  tubercular  origin.  Perioophoritis  has 
already  been  referred  to  as  a  complication  of  ovarian  tumours. 

The  disease  perimetritis  is  described  in  the  article  on  '•  Pelvic  Inflam- 
mation "  ;  here  I  have  only  to  indicate  certain  points  which  affect  the 
functions  of  the  ovary  and  the  health  of  the  individual. 

The  chief  function  of  the  ovary,  apart  from  any  supposed  "  internal 
secx'ction,"  is  to  provide  a  sight  for  the  maintenance  and  perfect  develop- 
ment of  healthy  ova,  to  allow  their  extrusion  under  certain  not  well 


862  SYSTEM  OF  GYNAECOLOGY 

ascertained  conditions,  and  to  discharge  tliem  in  a  position  wiico  they 
may  securely  find  entry  into  the  mouth  of  tlie  oviduct.  It  is  obvious,  on 
the  other  hand,  that  perioophoritis  will  be  likely  to  interfere  with  the 
extrusion  of  the  ovum  and  its  passage  into  the  oviduct.  For,  in  the  first 
place,  it  is  accompanied  by  a  thickening  and  induration  of  the  surface  of 
the  ovary,  which  interfere  Avith  or  prevent  the  rupture  of  the  Graafian 
follicles.  Thus  it  is  probable  that  the  rupture  may  be  prevented  by  the 
close  adherence  of  that  part  of  the  ovary  which  contains  the  follicle  to 
some  neighbouring  structure.  Or  the  ovum,  having  been  extruded,  may 
be  prevented  from  passing  into  the  oviduct  by  adhesions  fixing  the  fim- 
briated orifice  to  another  part  of  the  ovary. 

Adhesions  are  a  fertile  source  of  suffering,  especially  if  they  restrict 
the  free  mobility  of  the  ovary,  and  fix  it  in  a  position  where  it  is  subject 
to  undue  pressure.  The  patient  probably  suffers  pain,  localised  more  or 
less  distinctly  at  the  pelvic  brim,  and  extending  down  the  thigh  of  the 
affected  side.  Also  during  the  days  preceding  and  at  the  commencement 
of  the  menstrual  flow,  a  tender,  fixed  ovary  becomes  far  moi'C  tender 
owing  to  its  vascular  engorgement  at  this  time,  and  perhaps  to  the  further 
increased  tension  of  the  organ  already  confined  by  adhesions. 

It  is  believed  by  many  authors  that  an  inflammation  beginning  as  a 
perioophoritis  may  extend  beyond  the  surface  into  the  substance  of  the 
ovary,  and  produce  induration  and  other  changes  in  the  superficial  stroma, 
which  made  lead  to  dropsy  of  the  follicles  and  to  htemorrhage  with  con- 
sequent degeneration  of  the  ova.  Such  a  condition  is  known  as  "  cystic 
ovaritis."  Examination  of  some  enlarged  ovaries  affected  with  oopho- 
ritis certainly  appears  to  favour  the  view  that  fibrosis  may  arise  on  the 
surface  and  gradually  invade  the  deeper  tissues ;  but  before  we  can  feel 
sure  of  the  interpretation  of  the  details  observed,  we  must  attain  an 
accurate  knowledge  of  the  normal  ovarian  structure  at  different  periods 
of  adult  life. 

Oophoritis,  in  its  well-marked  forms,  like  perioophoritis,  is  part  of  a 
more  general  disease.  Even  where  there  are  no  signs  of  inflammation 
of  contiguous  structures,  and  where  this  appears  to  be  the  single  disease 
from  which  the  patient  is  suffering,  evidence  can  often  be  obtained  that 
it  arose  in  connection  with  some  such  disease  as  gonorrhoea ;  or  there 
may  be  evidence  of  tubercle  elsewhere ;  or  again,  it  may  be  the  only 
important  relict  of  an  extensive  septic  inflammation. 

Oophoritis  in  its  most  acute  forms  is  met  with  in  connection  Avith 
acute  pelvic  or  general  septic  inflammation  —  the  infection  having  gained 
admittance  through  lesions  of  the  vagina  and  uterus  arising  during 
labour,  abortion,  surgical  operation,  or  examination  or  accidental  injury 
of  the  parts.  If  the  ovary  were  previously  the  seat  of  cystic  disease, 
or  of  tubercle,  it  may  become  further  infected  and  inflamed  l)y  the  pas- 
sage of  septic  organisms  from  the  bowel  through  the  cyst  wall. 

The  continuity  of  structure  of  the  stroma  and  the  blood  and  lymph- 
vessels,  of  the  ovaries  and  Ijroad  ligaments,  readily  explains  the  extension 
of  inflammation  of  the  vagina  or  uterus  along  the  parametritic  connective 


DISEASES   OF   7 HE    OVARY  863 

tissue  to  the  ovary.  This  no  doubt  occurs;  probably  it  is  the  most 
frequent  course ;  but  in  many  cases  such  an  extension  cannot  be  traced. 

It  is  commonly  held  that  oophoritis  is  the  result  of  an  extension 
of  inflammation  from  the  uterus  along  the  oviduct,  the  infective  mate- 
rial escaping  from  the  open  mouth  of  the  tube  on  the  surface  of  the 
ovary.  This  supposition  does  explain  the  occurrence  of  joerioophoritis ; 
it  is  well  known  that  escape  of  pus  from  a  pyosalpinx  does  produce  a 
localised  or  general  peritonitis ;  and  it  may  be  the  fact  that  septic  mat- 
ter may  gain  access  to  the  interior  of  the  ovary  through  an  open  and 
ruptured  Graafian  follicle,  if  not  through  the  Ij-mph  spaces  on  the 
surface.  Wertheim's  (36)  investigations  appear  to  prove  conclusively 
that  gonococci  may  pass  directly  through  the  wall  of  the  Fallopian  tube 
into  the  substance  of  an  adherent  ovary,  or  into  the  broad  ligament, 
and  so  set  up  inflammation. 

The  most  acute  forms  of  oophoritis  are  those  resulting  from  septic 
infection  in  connection  with  child-birth,  abortion,  and  surgical  proced- 
ures. In  the  fatal  cases  the  ovary  may  be  much  enlarged,  soft,  and 
sloughing ;  or  in  less  severe  cases  small  extravasations  of  blood  or  pus 
may  be  seen  on  section  in  the  stroma  or  follicles ;  in  either  case  the 
uterus,  oviducts,  and  broad  ligament  will  be  found  in  a  condition  simi- 
lar to  that  of  the  ovary.  In  cases  where  death  has  occurred  within  a 
few  days  of  the  infection,  little  loculi  of  pus  can  often  be  found  in  the 
vessels  and  connective  tissue,  close  to  the  side  of  the  uterus  as  well  as 
in  the  uterine  walls;  and  the  mucous  membrane  of  the  oviducts  will  be 
found  acutely  inflamed.  Evidence  of  a  wide-spread  septic  process  is 
also  to  be  found  in  more  distant  structures. 

In  cases  of  acute  but  localised  septic  oophoritis  the  early  changes 
are  less  certainly  known ;  though,  as  a  result  of  the  surgical  procedure 
now  often  successfully  adopted,  the  later  stages  are  becoming  more 
familiar  to  us.  The  minute  foci  of  suppuration  either  disappear  by 
resolution,  or  they  extend  and  coalesce,  and  may  form  an  abscess  of 
considerable  size  —  the  size  of  a  hen's  e^g  or  larger.  The  very  large 
abscesses  of  the  ovary  are  probably  the  result  of  suppuration  of  cysts. 
Such  suppurating  ovaries  become  adherent  to  neighbouring  structures, 
and  if  the  walls  are  very  thick  the  abscess  may  remain  quiescent; 
nevertheless  it  may  produce  a  chronic  state  of  ill-health  and  suffering, 
or  it  may  open  into  the  bowel ;  indeed,  unless  it  be  thus  emptied  and 
the  cavity  enabled  to  shrink  up  and  ultimately  to  close,  the  patient 
passes  into  the  same  state  of  chronic  ill-health  as  that  produced  by  an 
unruptured  abscess,  and  under  such  circumstances,  unless  the  patient 
can  be  relieved  by  operation,  she  may  gradually  lose  ground  and  finally 
die  from  exhaustion  and  the  other  consequences  of  prolonged  suppuration. 

Oophoritis  Serosa.  —  There  is  quite  another  form  of  what  may  be 
called  inflammation  of  the  ovary  of  an  exceedingly  chronic  kind  — 
chronic  in  development,  very  chronic  in  duration,  but  in  the  majority  of 
cases  curable  under  proper  management.  It  is  met  with  in  cases  of  pro- 
longed ill-health  in  which  no  local  cause  can  be  recocrnised.     It  follows 


864  SYSTEM  OF  GYN.-ECOLOGY 

some  fevers,  it  has  occurred  in  two  cases  of  mumps  under  my  own  care, 
it  is  met  with  in  women  married  for  some  years  who  have  not  become 
pregnant :  in  some  of  these  cases  the  cause  of  the  sterility  may  be  a 
passive  goriorrhoeal  infection ;  indeed,  this  form  of  ooplioritis  appears 
to  be  that  most  frequently  produced  by  gonorrhoea,  and  in  some  cases 
it  is  accompanied  by  definite  salpingitis  and  perimetritis. 

Clinically  the  ovaries  are  found  to  be  swollen,  very  tender,  and 
often  prolapsed;  such  ovaries  have  frequently  been  removed  by  sur- 
geons. They  present  a  swollen,  congested  appearance  in  the  earlier 
stages ;  in  advanced  cases  they  are  extremely  swollen,  smooth,  shin}^, 
and  almost  translucent,  the  folds  and  cicatrices  being  sometimes  quite 
obliterated.  On  section  this  appearance  is  seen  to  be  due  to  oedema 
and  probably  consequent  anaemia  of  the  whole  organ.  This  condition 
in  various  degrees  of  severity  is  one  of  those  most  frequently  found  in 
cases  of  so-called  chronic  oophoritis.  It  is  often  called  oedema  of  the 
ovary,  but  better,  by  Olshausen  and  others,  "  oophoritis  serosa." 

In  very  many  cases  it  is  not  possible,  indeed  it  may  be  hardly  nec- 
essary, to  attempt  to  distinguish  cases  of  parenchymatous  from  those 
of  interstitial  oophoritis.  In  the  acute  septic  forms  the  follicles,  stroma, 
and  vessels  are  alike  affected ;  but  in  the  chronic  forms  there  are  un- 
doubtedly different  degrees  of  affection  of  the  stroma  and  follicles.  In 
the  cases  of  simple  oedema,  or  phlegmon,  it  is  the  stroma  that  shows 
the  most  marked  changes;  while  in  chronic  interstitial  oophoritis,  a 
condition  which  passes  by  insensible  gradations  into  the  various  forms 
of  fibroma  ovarii,  both  structures  are  affected,  though  to  a  varying  degree, 
in  different  cases.  In  some  the  ovary  is  enlarged,  by  a  marked  increase 
in  bulk  of  the  stroma,  to  three  or  four  times  its  natural  size ;  in  others 
the  distended  follicles  are  visible  over  the  whole  surface:  it  will  be 
noted  that  there  is  no  tendency  to  proliferation  of  these  little  cysts. 

All  authorities,  however,  following  Olshausen,  describe  these  states 
as  constituting  definite  varieties ;  and  many  attempt  a  more  minute 
classification :  but  to  give  distinctive  names  to  every  little  variation, 
such  as  is  produced  by  a  slight  additional  extravasation  of  blood,  seems 
more  likely  to  confuse  than  to  advance  pathology.  And  classification 
is  further  complicated  when  authors  describe  as  oophoritis  cases  in  which 
the  only  evidence  of  such  a  condition  is  the  presence  of  one  impor- 
tant clinical  symptom,  the  so-called  "  ovarian  pain,"  or,  as  it  should  be 
described,  pain  referred  to  the  region  of  the  ovary. 

The  name  ''cirrhosis"  is  applied  to  various  conditions  of  the  ovary, 
about  which,  in  the  absence  of  precise  knowledge,  there  is  no  general, 
agreement.  Some  apply  this  name  to  conditions  almost  physiological ; 
for  instance,  to  ovaries  shrunken  and  shrivelled  by  an  atrophy,  some- 
times perhaps  prematurely  senile;  others  to  conditions  of  the  ovary,  the 
only  abnormality  of  which  is  an  unusual  degree  of  cicatricial  Assuring  of 
the  surface,  -  -tlie  result  in  some  cases,  undoubtedly,  of  an  early  develop- 
mental variation,  but  apparently  much  more  often  the  result  of  active 
ovulation;  while  others  again,  with  greater  propriety,  restrict  the  term 


DISEASES   OF  THE    OVARY  865 

to  the  minor  degrees  of  fibrosis  with   more  or  less  dilatation  of   the 
Graafian  follicles. 

Tubercular  oophoritis  should  be  considered  not  only  in  relation  to 
tubercle  of  the  other  genital  organs,  but  in  relation  to  tuberculosis  in 
general ;  for,  as  I  have  shown  in  a  communication  to  the  Pathological 
Society  of  London  (10),  the  ovary  is  one  of  the  least  common  seats  of 
tubercle,  and  when  tuberculous,  it  is  almost  invariably  in  association 
with  tubercle  elsewhere;  as  for  instance  in  the  lungs,  lymph  glands, 
meninges  of  the  brain,  peritoneum,  oviducts,  and  uterus. 

Tubercle  is  found  to  affect  the  ovary  in  two  distinct  forms :  (a) 
miliary  tubercle  of  the  surface,  usually,  but  not  invariably,  associated 
with  tubercle  of  the  peritoneum  and  leading  to  tubercular  perioophoritis ; 
(6)  miliary  tubercle  in  the  substance  of  the  ovary,  which,  undergoing 
caseation,  usually  suppurates,  and  eventually  leads  to  abscess. 

In  the  first  class  of  cases  the  ovary  may  be  of  normal  size,  or  may  be 
the  seat  of  cystic  or  other  disease.  There  are  no  special  symptoms,  and 
the  disease  is  only  recognised  on  inspection  of  the  ovary  during  opera- 
tion or  after  death. 

In  the  second  variety  the  later  stages  of  abscess  are  now  well  known ; 
the  diagnosis  of  the  tubercular  origin  of  the  disease  is,  however,  a  mat- 
ter of  surmise  until  the  ovary  is  itself  examined  after  removal.  Its  size 
and  physical  characters  naturally  depend,  not  only  on  the  extent  of  the 
tuberculous  disease,  but  on  the  degree  of  suppuration.  In  this  form  of 
disease  caseous  masses  will  often  be  found  in  the  abscess  cavities,  and 
miliary  or  caseating  tubercles  in  other  parts  of  the  organ.  The  earlier 
stages  of  the  second  variety  are  not  rarely  met  with,  and  the  gross  physi- 
cal characters  need  further  investigation ;  very  few  specimens  have  been 
fully  described  (4). 

The  ovary  is  found  to  be  enlarged,  even  perhaps  to  the  size  of  a 
small  apple,  without  suppuration ;  though  it  is  not  by  any  means  cer- 
tain whether  this  enlargement  be  due  solely  to  the  tubercular  affection. 
Even  if  there  be  no  caseation,  and  the  bacilli,  as  usual  in  this  form,  very 
few  and  hard  to  find,  the  microscope,  by  revealing  the  histological  char- 
acters of  tubercle,  will  place  the  diagnosis  beyond  doubt. 

The  variety  described  by  Whitridge  Williams  (37),  in  his  valuable 
paper  under  the  name  of  "Unsuspected  Genital  Tuberculosis,"  does 
not  seem  to  deserve  to  be  raised  into  a  special  class.  We  may  reason- 
ably expect  that  as  our  knowledge  of  this  affection  increases  the  cases 
included  in  this  particular  variety  will  become  rarer. 

Hegar,  Olshausen,  and  Whitridge  Williams  discuss  the  possible  mode 
by  which  tubercular  infection  of  the  female  genital  organs  can  take  place, 
but  there  seems  no  reason  to  suppose  that,  with  the  possible  exception  of 
infection  by  semen,  the  manner  of  infection  of  these  organs  differs  from 
that  of  other  parts.  The  age  of  the  youngest  patient  recorded  in  the 
author's  paper  was  five  years,  the  oldest  fifty-five  ;  five  were  under  four- 
teen years,  eight  were  between  fourteen  and  twenty-five,  three  between 
twenty-five  and  forty-five,  and  one  was  fifty-five. 

3k 


866  SYSTEM   OF  GYNECOLOGY 

The  ovary  ranks  third  in  the  order  of  frequency  with  which  tlie 
female  organs  are  affected  Avith  tubercle  ;  the  oviducts  and  mucous  mem- 
brane of  the  body  of  the  uterus  being  first  and  second  respectively. 

The  question  of  oophorectomy  in  a  case  in  which  the  disease  of  one 
ovary  is  suspected  to  be  tubercular  in  origin,  is  one  of  comparatively 
easy  solution;  as  in  such  cases  the  disease  will  lead  in  the  majority  of 
instances  to  suppuration,  and  the  treatment  will  be  determined  on  general 
surgical  principles.  And  if  there  is  a  strong  probability  of  the  presence 
of  tubercular  disease  in  the  ovary,  and  a  marked  absence  of  evidence  of 
it  from  other  organs,  there  can  be  little  doubt  that  the  most  conservative 
treatment  is  the  removal  of  the  affected  parts  by  a  complete  operation. 
The  oviducts  will  almost  invariably  have  to  be  removed  at  the  same  time. 

The,  si/mjytoms  of  oophoritis  are  by  no  means  easily  distinguishable 
from  those  due  to  inflammation  of  other  pelvic  viscera,  which,  indeed, 
is  usually  present  at  the  same  time.  In  cases  of  acute  septic  poisoning, 
with  the  most  active  destruction  of  the  ovary,  we  know  of  no  symptoms 
significant  of  the  ovarian  lesion ;  the  disease  is  septicsemia,  and  we  do 
not  attempt  to  analyse  the  symptoms  or  to  recognise  the  manifestations 
of  the  disease  in  an  organ  so  unimportant  to  life. 

It  is  in  the  less  severe  inflammations  that  we  are  able  to  recognise 
symptoms  with  distinguishing  characters,  and  in  some  of  them  by 
phy.sical  examination  to  diagnose  the  lesser  forms  of  oophoritis.  All 
forms  of  oophoritis  are  so  intimately  associated  with  inflammation  of 
the  oviducts  and  the  surrounding  peritoneum,  that  in  the  present  state 
of  our  knowledge  I  can  only  describe  the  general  symptoms. 

Pain  is  the  one  constant  symptom  of  all  varieties  of  pelvic  inflamma- 
tion, and  the  site  to  which  it  is  referred  by  the  patient  bears  no  constant 
relation  to  the  organ  affected.  The  whole  region  below  the  navel  and 
above  the  pelvic  brim,  from  the  pubes  to  the  iliac  spines,  back  to  the 
loins  and  sacrum,  and  down  the  thighs  to  the  knees,  is  or  may  be  the 
seat  of  pain  in  various  circumstances  ;  but  we  have  no  trustworthy  means 
by  which  we  can  distinguish  one-sided  pains  due  to  affections  of  the  tube, 
ovary,  peritoneum,  broad  ligament,  or  the  body  of  the  uterus  or  the  cervix. 

Those  who  have  read  Dr.  Head's  valuable  work  on  localisation  of 
pain  due  to  visceral  disease  (11),  may  be  disappointed  that  greater  practi- 
cal results  have  not  as  yet  followed  in  this  and  in  some  other  regions  of 
the  body  from  his  investigations,  which  are  of  the  highest  value,  and  which 
must  in  time  lead  to  very  important  results.  The  reasons  in  this  case  are 
obvious;  the  four  areas  localised  by  him,  namely,  10th,  11th,  and  12th 
dorsal,  and  1st  lumbar,  are  common  in  different  degrees  to  the  ovary, 
tube,  and  body  of  the  uterus ;  and  further  investigation  is  necessary  to 
enaljle  us  to  distinguish  disease  confined  to  one  of  these  organs  :  indeed, 
tlie  commcm  diseases  causing  ])ain  most  frequently  affect  all  these  parts. 

Tlie  pain  is  aggravated,  as  are  all  ])ains  due  to  inflammation,  by  any 
increase  of  yn'cssure  on  or  within  the  ovary.  The  most  important  cause 
of  increased  tension  within  is  the  premenstrual  and  menstrual  vascular 
congestion,  which  will  set  \ip  severe  pain  at  this  time.    The  pain  is  easily 


DISEASES   OF  THE    OVARY  867 

distinguished  from  that  called  true  dysmenorrhoea,  by  the  fact  that  it  is 
the  aggravation  of  a  pain  which  continues  between  the  periods ;  while 
true  dysmenorrhoia  is  a  purely  menstrual  pain.  There  are,  apparently, 
exceptions  to  the  rule  of  menstrual  increase  of  pain,  for  we  meet  some- 
times with  patients  who  say  that  the  only  time  they  are  free  from  pain 
is  during  the  menstrual  flow. 

The  pain  that  persists  after  coitus  may  also  be  due  in  some  cases  to 
congestive  tension. 

The  most  constant  source  of  pain  from  pressure  is  the  general  intra- 
abdominal pressure  of  the  various  viscera  on  each  other,  increased  by  all 
straining  efforts  even  of  a  comparatively  slight  kind.  Such  pain  is  re- 
lieved gradually  by  the  horizontal  position  ;  some  patients  spontaneously 
lie  on  the  back,  others  on  the  chest  or  side. 

Pain  is  also  caused  by  direct  pressure  on  the  organs  through  the 
abdominal  walls,  the  vagina,  or  rectum ;  as  for  instance  during  a  medical 
examination,  or  coitus,  or  the  passage  of  large  faecal  masses. 

Of  the  other  great  symptoms  of  pelvic  disorder,  haemorrhages,  men- 
strual or  intermenstrual,  amenorrhoea,  and  leucorrhrea,  none  is  known 
to  be  characteristic  of  oophoritis.  The  presence  or  absence  of  any  one 
of  them  probably  depends  largely  on  the  extent  of  the  inflammation  of 
the  uterus  itself,  and  on  the  general  state  of  the  patient's  health. 

Reference  must  not  be  omitted  to  the  wide  distribution  of  neurotic 
symptoms  frequently  met  with  in  women  suffering  from  various  pelvic 
ailments,  amoiigst  them  ovarian.  To  discuss  this  subject  adequateh* 
would  require  a  space  beyond  that  allotted  to  me,  but  it  may  safely  be 
said  (a)  that  the  local  pelvic  lesion  is  most  frequently  a  minor  one ;  (b) 
that  different  authors  attribute  these  symptoms  to  lesions  of  various 
organs,  the  commonest  lesions  being  oophoritis,  displacements  of  the 
uterus,  and  fissures  of  the  cervix ;  (c)  that  the  symptoms  are  not  gener- 
ally met  with  in  women  of  robust  minds,  who  suffer  from  the  same 
very  common  local  lesions ;  (d)  that  the  nerve  symptoms  have  a  great 
tendency  to  persist  after  the  cure  of  the  local  lesion ;  (c)  and  that  the 
greatest  benefit  is  obtained  by  attention  to  the  principles  of  general 
treatment,  that  is,  by  a  treatment  tending  to  restore  and  increase  the 
vigour  of  the  mind  in  a  more  vigorous  body  —  a  restoration,  however,  by 
no  means  always  practicable.  Such  cases  form  a  great  source  of  gain  to 
all  kinds  of  quack  practitioners ;  and  while  some  of  them  are  cases  of 
great  and  permanent  success  and  satisfaction  to  the  rational  and  honoura- 
ble practitioner,  n^any  are  a  continual  source  of  disappointment  to  all 
whose  misfortune  it  is  to  be  their  relatives  or  medical  advisers. 

Diagnosis  of  oophoritis  can  be  made  in  some  cases  with  practical  cer- 
tainty, when  the  finger  in  the  rectum,  or  less  frequently  in  the  vagina, 
recognises  a  tender  body  of  the  shape  of  the  healthy  organ,  but  some- 
what larger,  lying  to  one  side  of  or  behind  the  nterns  and  broad  ligament. 

Fixation  by  adhesions  interferes  with  this  ready  recognition,  and 
unless  special  means  be  adopted  to  make  the  examination  under  the 
most  favourable  circumstances,  there  Avill  constantly  be  doubt  as  to  how 


86S  SYSTEM  OF  G\\V.-ECOLOGY 

much  of  the  swelling  is  ovary,  how  much  tube,  and  how  much  adhesions 
and  surrounding  effusion. 

The  most  favourable  conditions  for  examination  of  a  difficult  case  are 
an  absence  of  obesity,  the  influence  of  an  amesthetic,  the  lithotomy  posi- 
tion, the  evacuation  of  the  rectum  and  bladder,  and  the  drawing  down 
of  the  uterus  hy  a  suitable  instrument.  Even  with  these  advantages  it 
is  not  surprising  that  we  are  foiled  at  times  in  our  search  for  precise 
knowledge ;  while  in  some  cases,  even  after  removal  of  the  organs,  there 
is  great  doubt  how  much  is  ovary  and  how  much  tube.  And  when  we 
do  succeed,  our  success  is  more  a  source  of  satisfaction  to  our  pride  than 
a  benefit  to  our  patient,  whose  treatment,  whether  by  operation  or  by  a 
prolonged  course  of  medical  means,  is  not  materially  affected  by  the 
seat  of  the  disease,  Avhether  it  be  in  ovary  or  tube ;  the  essential  thing 
is  the  diagnosis  of  the  presence  of  inflammation,  its  degree,  its  duration, 
and  its  effects. 

Treatment.  —  The  general  principles  which  govern  the  treatment  of 
inflamed  ovaries  are  common  to  all  cases  of  pelvic  inflammation;  and 
the  most  valuable,  namely,  rest  in  bed,  may  easily  be  carried  too  far, 
especially  in  the  slighter  cases ;  great  care  is  also  needed  in  watching 
the  patient  to  observe  the  effects  of  this  treatment  on  the  general 
health,  as  well  as  on  the  local  condition ;  in  order  that  the  physician 
may  be  enabled  to  put  a  proper  term  to  it.  And  the  same  close  attention 
must  be  paid  to  the  effects  of  drugs  for  the  relief  of  pain.  Acute  pain 
must  be  relieved :  to  this  end  hot  apfjlications  to  the  hypogastric  region 
are  effectual,  and  hot  vaginal  injections  also,  though  to  a  less  extent; 
more  direct  relief  will,  in  some  cases,  have  to  be  afforded  by  such  drugs 
as  opium.  In  the  protracted  cases  the  application  of  heat  will  soon 
lose  its  good  effects ;  anodynes  will  not  only  fail  likewise,  but  will 
become  a  positive  source  of  danger  to  the  patient :  if  the  suffering  is 
genuine  and  severe,  and  not  out  of  all  proportion  to  the  ascertained 
lesions,  removal  of  the  inflamed  organ  by  operation  will  have  to  be  con- 
sidered, and  probably  adopted.  But  in  cases  where  the  lesions  are  small 
and  the  nerve  symptoms  great,  the  treatment  shoidd  be  radically  differ- 
ent ;  we  should  endeavour  in  every  way  to  improve  the  general  health, 
and  neglect  the  local  disorder  as  far  as  possible. 

HEMATOMA  OF  TiiK  OvARY. — Extravasation  of  blood  into  the  ovary  is 
not  rare,  but  our  knowledge  of  the  condition  is  certainly  not  very  precise. 

It  is  easily  recognisable  in  three  forms  :  ha3morrhage  into  the  stroma; 
•into  Graafian  follicles ;  and  into  cysts,  such  as  cystic  follicles,  cysts  of 
the  corpora  lutca,  and  large  proliferating  cysts.  Ilijcmorrhage  into  cysts 
from  strangulation  of  the  pedicle,  or  from  rupture  of  the  vessels  in  the 
very  vascular  papillary  or  glandular  masses  in  their  walls,  has  already 
been  described,  page  850. 

Cysts  of  the  corpus  luteum  are  small  and  commonly  filled  with  blood, 
the  result  probably  of  degeneration  of  the  walls  and  consequent  rupture 
of  some  vessels. 


DISEASES   OF   THE    OVARY  869 

Minute  haemorrhage  into  the  stroma  or  follicles  is  also  not  very  rare, 
and  appears  to  have  some  connection  with  conditions  where  there  is  con- 
siderable and  persistent  uterine  haemorrhage. 

Such  hiemorrhages  into  the  stroma  occur  also  in  acute  septic  oopho- 
ritis, and  during  menstruation,  apparently  normal,  into  the  follicles ; 
Winckel  found  them  in  cases  of  heart  disease,  typhus  fever,  phosphorus 
poisoning,  and  in  three  cases  of  extensive  burns. 

Sometimes  the  haemorrhage  into  the  stroma  appears  to  be  secondary, 
the  result  of  a  ruptured  follicle  distended  with  blood.  Haemorrhage  into 
the  ovary,  apart  from  haemorrhage  into  cysts,  is  of  importance  because 
of  its  effects  in  increasing  the  size  and  Aveight  of  the  ovaries,  and  thus 
becoming  the  cause  of  pain  and  prolapse.  It  is  probable  that  in  slight 
degrees  it  may  be  a  more  frequent  cause  of  painful  and  tender  ovaries 
than  is  generally  supposed. 

We  have  no  means  of  diagnosing  this  condition ;  we  recognise  it 
merely  as  a  pathological  phenomenon. 

Prolapse  of  the  Ovary.  —  The  position  of  the  ovaries  in  a  healthy 
woman,  lying  as  they  do  loosely  attached  to  the  superior  surfaces  of 
the  broad  ligaments  (these  being  more  nearly  horizontal  than  vertical  in 
the  erect  position)  and  to  the  sides  of  the  uterus,  admits  readily  of  their 
descent  on  the  utero-sacral  folds,  or  farther  into  Douglas'  pouch,  if  the 
normal  conditions  of  their  support  are  disturbed.  The  abnormal  condi- 
tions producing  this  prolapse  are  an  increase  in  weight  of  the  ovaries,  and 
prolapse,  retroversion,  or  retroflexion  of  the  uterus  and  broad  ligaments. 

The  actual  prolapse  may  be  sudden,  the  result  of  a  strain ;  more  often 
it  takes  place  gradually. 

Prolapse  of  the  ovaries  is,  therefore,  only  one  phenomenon  complicat- 
ing various  disorders  of  the  pelvic  organs;  but  it  deserves  special  attention 
from  the  frequency  of  its  occurrence,  and  from  the  important  symptoms 
to  which  it  may  give  rise :  for  it  not  unfrequently  happens  that  the  symp- 
toms due  to  the  prolapse  are  the  only  important  symptoms  present. 

Prolapsed  ovaries  ma}^  become  fixed  in  their  abnormal  position  by 
adhesions  ;  a  serious  complication,  as  it  renders  relief  almost  impossible 
except  by  means  of  operation. 

The  conditions  of  the  ovary  which  cause  its  enlargement  are  described 
elsewhere:  these  are  simple  oedema,  inflammation,  tubercle,  haeraatoma, 
and  incipient  tumour  formation.  Displacements  of  the  uterus  are  also 
dealt  with  elsewhere  in  this  System. 

I  have  here  only  to  describe  the  symptoms,  diagnosis,  and  treatment 
of  the  prolapse. 

8>/mptomn. — Prolapse  of  an  ovary  is  a  displacement  of  a  sensitive 
organ  from  a  jjosition  of  free  mobility  and  of  security  from  violent 
pressure  (namely,  between  the  elastic  bowels  and  broad  ligaments)  to  a 
position  in  Avhich  its  mobility  is  very  much  restricted  (especially  if  both 
ovaries  are  prolapsed  into  Douglas'  pouch),  and  where  it  is  very  liable 
to  be  squeezed  bj'^  the  suVrounding  pai'ts  as  the  result  of  general  intra- 


870  SYSTEM   OF  GYNECOLOGY 

abdominal  pressure,  varying  with  muscular  exertion  and  with  the 
distension  of  bowels  and  bladder.  These  changes  cause  more  or  less 
constant  aching,  and  the  pain  is  increased  as  the  menstrual  conges- 
tion recurs.  Furthermore,  the  organs  are  liable  to  special  pressure 
during  coitus,  and  during  the  passage  of  large  or  hard  faecal  masses 
through  the  rectum  —  both  of  which  disturbances  cause  sudden  and 
severe  paroxysms  of  pain. 

A  prolapsed  ovary  is  usually  swollen,  and  is  more  sensitive  to  press- 
ure than  in  its  natural  position ;  but  it  is  not  easy  to  say  whether  these 
changes  are  due  to  the  prolapse  or  not.  The  conditions  under  which 
prolapse  occurs  are  such  as  would  usually  cause  swelling,  and  conse- 
quently increased  sensitiveness  of  the  organs. 

Diagnosis.  —  This  is  comparatively  easy  in  the  case  of  simple  pro- 
lapsed, non-adherent  ovaries ;  a  movable,  sensitive,  often  very  tender 
swelling  of  the  shape  of  the  healthy  ovary,  but  usually  of  a  somewhat 
larger  size,  is  found  lying  behind  the  uterus  and  (if  completely  pro- 
lapsed, behind  the  upper  inch  of  the  vagina)  in  front  of  the  rectum. 

When  there  are  adhesions  it  is  often  not  at  all  easy  to  distinguish 
the  ovary  from  the  prolapsed  distended  extremity  of  the  oviduct. 

Tlie  treatment  of  prolapsed  ovaries  is  always  a  very  troublesome 
matter ;  in  itself  it  is  a  minor  disease,  but  unless  relieved,  it  may  be  a 
source  of  continual  and  great  suffering  to  the  patient  until  the  climac- 
teric is  well  passed. 

If  the  prolapsed  ovary  be  movable  and  not  greatly  enlarged,  and 
particularly  if  the  uterus  is  retroverted,  retroflexed,  or  prolapsed,  relief 
can  be  given  by  carefully  replacing  the  uterus,  and  supporting  it  and 
the  broad  ligaments,  and,  therefore,  to  a  certain  extent  the  ovaries,  by 
a  suitable  pessary  of  the  "  Hodge  "  type ;  or,  if  that  cannot  be  borne,  by 
an  india-rubV)er  ring.  The  patient  in  such  cases  should  never  be  kept 
lying  on  her  back.  So  long  as  rest  is  necessary  she  should  lie  in  such 
a  way  that  the  tendency  to  prolapse  of  the  ovaries  is  the  least,  and  this 
will  be  on  the  chest  or  in  the  semiprone  position.  This  method,  com- 
bined with  attention  to  the  general  health,  is  usually  successful. 

When  the  prolapsed  ovary  is  adherent,  and  proper  treatment  fails 
within  a  reasonal)le  time  to  get  rid  of  the  adhesions,  and  allow  the  ovary 
to  return  to  its  natural  position,  great  relief  can  be  given  by  an  opera- 
tion through  the  vagina  or  abdominal  wall,  having  as  its  object  the 
release  of  the  fixed  ovary  from  its  prolapsed  position,  saving  it,  if  pos- 
sible, and,  if  necessary,  fixing  it  higher  up  where  the  pressure  effects 
are  far  less  likely  to  be  injurious. 

The  operation  through  the  vagina  —  anterior  colpotomy  —  is  destined, 
perhaps,  to  take  the  place  of  the  abdominal  operation  in  the  majority  of 
cases,  when  further  experience  has  enaV)led  us  to  select  the  proper  cases 
with  certainty  ;  the  operation  is  one  of  loss  immediate  risk  tlian  abdomi- 
nal section,  and  it  is  free  from  the  i-isk  of  the  sul)sequent  formation  of 
a  ventral  hernia. 

We  know  of  no  drugs  which  have  any  direct  effect  on  the  structure  or 


DISEASES   OF  THE    OVARY  871 

functions  of  the  ovary  ;  its  minor  diseases  are  best  treated  by  general 
means,  such  as  fresh  air,  exercise,  proper  food,  daily  evacuation  of  the 
bowels,  and  tonics ;  with  avoidance  of  injui-ious  pursuits  and  occupa- 
tions. Ovarian  pain,  in  the  absence  of  severe  lesions,  will  be  most 
readily  and  permanently  relieved  by  such  measures. 

Hernia  of  the  Ovary.  —  This  is  a  rare  form  of  displacement  of  the 
ovary,  but  the  condition  is  one  of  considerable  practical  importance.  It 
may  be  congenital  or  acquired ;  Avhen  congenital  it  is  associated  with 
persistence  of  the  canal  of  Nuck,  into  which  the  ovary  descends ;  Avhen 
acquired  it  is  usually  inguinal  in  position :  cases  are  recorded,  however, 
in  Avhich  the  ovary  has  passed  out  of  the  pelvis  through  the  crural  canal 
(femoral  hernia),  the  great  sacro-sciatic  notch  (gluteal  hernia),  the 
umbilicus  (umbilical  hernia),  or  the  linea  alba  (ventral  hernia).  The 
condition  may  be  single  or  double. 

The  greater  number  of  cases  occur  in  early  youth,  but  not  all  of  these 
are  congenital.  Mr.  Bland  Sutton  rightly  emphasises  the  importance  of 
extreme  caution  in  diagnosing  this  condition  in  little  girls.  In  the 
well-known  case  recorded  in  the  Obstetrical  Society's  Transactions  by 
Chambers,  the  supposed  ovaries  turned  out  on  microscopic  examination  to 
be  testes ;  and  it  is  well  established  that  in  some  hermaphrodites  a  well- 
developed  uterus  and  external  genitals  may  coexist  with  testes  ivide  art.  on 
"Malformations"].  This  fact  illustrates  the  necessity  of  a  microscopic 
examination  of  the  bodies  removed  in  all  cases  of  supposed  ovarian  hernia 
in  childhood.  At  this  period  the  condition  seldom  gives  rise  to  trouble, 
but  occasionally  the  ovary  becomes  strangulated  and  has  to  be  removed. 

Symptoms.  —  Some  cases  remain  undiscovered  until  puberty,  when  the 
ovary  forms  a  firm,  almond-shaped,  generally  movable  body  in  the  groin 
or  the  labium  majus,  and  is  liable  to  be  mistaken  for  a  lymphatic  gland  or 
a  labial  tumour.  At  the  menstrual  periods  the  body  is  stated  to  become 
enlarged,  painful,  and  tender.  Sometimes  it  gives  rise  to  continual  pain, 
and  the  patient  thereby  becomes  a  chronic  invalid.  The  condition  is  no 
hindrance  to  conception,  and  during  pregnancy  the  ovary  may  increase 
greatly  in  size  and  become  very  painful ;  this  appears  to  result  when  the 
displaced  ovary  is  the  seat  of  the  corpus  luteum  of  pregnancy.  In  such 
cases  abortion  is  apt  to  occur.  Occasionally  a  herniated  ovary  becomes 
drawn  up  into  the  abdomen  during  pregnancy,  by  the  expansion  and  rise 
of  the  fundus ;  but  it  reappears  after  confinement,  unless  a  radical  cure 
be,  as  it  should  be,  effected  by  operation. 

The  displaced  ovary  is  sometimes  accompanied  by  the  Fallopian  tube, 
and  more  rarely  by  the  uterus  itself,  or  one  horn  of  a  double  uterus. 
Sometimes  it  appears  to  be  drawn  into  the  sac  by  adhesion  to  a  knuckle 
of  bowel  or  piece  of  omentum.  Frequently  the  ovary  becomes  cystic,  or 
otherwise  diseased;  and  a  case  of  a  gluteal  cyst  is  mentioned  by  Boinet 
which  was  found  on  removal  to  be  ovarian  in  origin. 

Tlie  diagnosis  must  in  all  cases  be  tentative  until  verified  by 
microscopic  examination.     When   the  hernia  is  irreducible  and  gives 


872  SYSTEM  OF  GYNvECOLOGY 

rise  to  considerable  trouble,  there  can  be  no  doubt  of  the  propriety  of 
surgical  interference. 

W.  S.  A.  Griffith. 

REFERENCES 

1.  Amaxn.  "  Ueber  Ovarialsarkome," -(4 ?'c/iiu /«?•  Gyw.  1894,  p.  48i. — 2.  Auten- 
REiCH.  Archiv  fiir  Physiol.  Halle,  vol.  vii.  p.  261.  — 3.  Boinet.  Maladies  des 
ovaires,  p.  73. — 4.  Chambers.  Trans.  Obst.  Soc.  Lond.  vol.  xxi.  269.-5.  Doran. 
Tumours  of  the  Ovary,  18S4.  —  6.  Edmunds.      Trans.  Path.  Soc.  Lond.  vol.  xl.  p.  210. 

—  7.  FiscHEL.  Archiv  fiir  Gyn.  Bd.  xv.  p.  198. — 8.  Flaischler.  "  Zur  Lehre 
der  Entwickelung  der  papillare  Cysto."  Zeit.  fiir  Geb.  und  Gyn.  Bd.  vi.  231.-9. 
Freuxd.  Arch,  fiir  Gyn.  June  4,  1892.  — 10.  Griffith.  Trans.  Path.  Soc.  Lond. 
vol.  xl.  p.  212;    Trans.  Obst.  Soc.  Lond.  1891,  p.  140. — 11.    Head.     Brain,  vol.  xvi. 

1893.  — 12.  Hegar.  Die  Entstehunq  u.  der  Genitaltuberkulose  des  Weibes.  Stuttgart, 
18)j6.  — 13.  JoNE-i,  Dixon.  N.  Y.  Med.  Journ.  May  1890.  — 14.  Klebs.  "  Beitrag  zur 
Kenntniss  der  Ovariotomie  und  der  Ovarialgeschwiilste,"  Virchow's  Archiv,  Bd.  xlix. 
p.  298. — 1.5.  Klob.  Handbiich  der  pathologi.-icher  Anatomic. — 16.  Kolaezek.  Virchow's 
Archiv,  Bd.  Ixxv.  p.  399. — 17.  Landerer.  Zeit.  f.  Geb.  und  Gyn.  Bd.  xxxi.  1895. 
— 18.  Leopold.  "Die  soliden  Eierstocksgeschwiilste,"  Archiv  fiir  Gyn.  Bd.  vi.  p. 
189.  —  19.  Marchand.  Beiti-cige  zur  Kenntniss  der  Ovarialtumoren,  1879.  —  20. 
Olshausex.  Die  Kranlcheiten  iter  Ovarien,\^SQ.—1\.  Pfannenstiel.  Zeit.  f.  Geh. 
und  Gyn.  Bd.  xxviii.  p.  349;  Archiv  fiir  Gyn.  Bd.  xl.  p.  ."63.-22.  Rindfleisch. 
Handbuch  der  pathologischen  Anatonne.—2'S.  Rokitansky.  "  Ueber  die  Cysto.' 
Denkschrift  der  Aknd.  a  Wissen.  zu  Wien.  1849. — 24.  Rosthom,  von.  Archiv  f.  Gyn. 
Bd.  xli.  p.  318.  —  25.   Schultze.     Zeitschrift  der  Gesell.  fiir  Geb.  und  Gyn.     Berlin, 

1894,  p.  841.— 26.  Shattock.  Trans.  Path.  Soc.  Lond.  1889,  p.  208.— 27.  Simpson. 
Obitet.  Trans.  Edinb.  1893-4,  p.  162. — 28.  Sinety,  de,  and  Malassey.  Compt.  rend,  de 
la  Soc.  de  Biol,  de  Paris,  1876. — 29.  Spiegelberg.  Monats.  fiir  Gsburtskunde,  Bd. 
XXX.  p.  380.  —  30.  Steffeck.  Zeit.  fiir  Geh.  und  Gyn.  1894,  p.  147.  —  31.  Sutton. 
Diseas-'s  of  Ovaries  and  Fallopian  Tubes,  1896. — 32.  Thornton.  Trans.  Obst.  Soc. 
Load.  1882,  p.  80.  —  33.  Velits,  von.  Virchow's  Archiv,  Bd.  cvii.  p.  805. — 34.  Vir- 
chow.  "  Ueber  chron.  Affect,  des  Uterus  und  der  Eierstocke,"  Wiener  med.  Woch. 
18,56. —35.  Waldeyer.  Eie7-stock  und  Ei.  1810.  — 3().  Wertheim.  Arch,  fiir  Gyn. 
Bd.  xlii. — 37.  Williams,  Whitridge.    Johns  Hopkins  Hospital  Reports,  vol.  iii.  1893. 

—  38.  Winckel.     Pathologic  der  weiblichen  Sexualorganes,  1881.    Leipzig. 

W.  S.  A.  G. 


OVARIOTOMY 


Ovariotomy  is  the  term  applied  to  the  operation  of  removal  of 
tumours  of  the  ovary.  It  has  also,  and  conveniently,  been  made  to 
include  operations  for  removal  of  growths  in  the  paroophoron,  the 
parovarium,  and  the  broad  ligaments ;  this  practice  will  l)e  followed 
here.  The  general  description  of  the  operation  will  be  given  for  the 
most  common  and  best  known  variety  of  ovarian  tumour,  the  glandular 
cystoma ;  variations  in  the  proceeding  will  be  described  for  solid 
growths  ;  for  dermoid  tumours ;  and  for  growths,  simple  and  papilloma- 
tous, which  open  up  the  layers  of  the  broad  ligaments. 

Ovariotomy  holds  the  proudest  of  positions  amongst  major  surgical 
opei-ations.  It  cures  acertaiidy  fatal  disease  without  leaving  deformity 
and  without  chance  of  recurrence;  and  this  with  a  risk  to  life  which  is 


OVARIOTOMY  873 


less  than  in  any  other  major  operation.  It  is  a  supreme  test  of  skill  in 
the  surgical  art.  Imperfect  art  or  science,  bad  surroundings  or  nursing, 
will  as  certainly  be  followed  by  disasters,  as  the  opposite  will  be  followed 
by  success.  Thanks  to  those  who  have  gone  before  us,  we  have  inherited 
a  code  of  rules  for  the  performance  of  ovariotomy  which  are  probably 
more  complete  than  for  any  other  operation ;  the  man  who  knows  these, 
and  who  has  helped  to  apply  them,  will  have  success  in  his  work. 
Xothing  can  replace  personal  knowledge  and  experience.  It  is  not 
enough  to  know  everything  that  has  been  written,  nor  even  to  have 
assisted  at  many  operations ;  the  best  operator  must  have  both  advan- 
tages. The  very  success  of  the  operation  has  been  its  curse.  The  man 
of  the  old  regime  who  considers  that  the  mortality  of  a  given  operation 
is  measured  by  the  ability  of  the  man  who  has  passed  his  examinations 
and  nothing  more,  will  soon  find  his  mistake  here.  The  highest  success 
in  ovariotomy  follows  the  highest  training  in  art,  and  the  most  thorough 
education  in  science. 

It  has  been  one  of  the  pleasing  features  of  the  history  of  the 
operation,  that  its  introduction  -was  due  to  the  genius  of  men  who  sought 
rather  to  save  lives  of  patients  than  to  increase  their  reputation  or  even 
to  advance  surgery.  The  scientific  disquisitions  of  men  like  Willius. 
Delaporte,  Morand,  Hunter,  Chambon,  Bell,  and  others  had  their 
influence ;  it  remained  for  the  keenly  anxious  practitioner  seeking  only 
the  salvation  of  his  patient  to  put  them  into  practice.  Ephraim 
M'Dowell,  settled  in  the  backw^oods  of  America,  was  in  1809  the  first 
of  these,  thanks  to  his  Edinburgh  teaching;  Jeaffreson  and  King,  both 
village  practitioners  in  England,  followed.  Clay  of  Manchester  took  up 
the  thread  of  success ;  then,  in  the  hands  of  Wells  in  London,  Keith 
in  Edinburgh,  and  Tait  in  Birmingham,  it  was  successfully  established  in 
the  large  towns  as  a  great  life-saving  operation.  Increase  of  success  has 
follow^ed  the  knowledge  which  these  masters  have  bequeathed  in  tech- 
nique, and  Lister  has  introduced  in  science.  At  the  present  day  it  may 
be  truly  said  that  ovariotomy  has  scarcely  any  legitimate  mortality. 
The  cases  that  die  are  the  neglected  ones  —  those  which  have  not  been 
diagnosed  till  far  advanced;  those  in  which  accidental  complications 
have  been  permitted ;  and  those  which  have  been  repeatedly  tapped. 

The  actual  death-rate  of  all  ovariotomy  operations  is  not  easily  got 
at;  probably  it  is  still  over  ten  per  cent.  In  the  hands  of  surgeons  of 
the  greatest  skill  and  experience  it  is  about  five  jier  cent.  Successful 
series  of  a  hundred  cases  and  over  have  been  secured  by  several  surgeons 
—  by  myself  amongst  the  number.  In  the  last  fifteen  years,  at  least 
half  a  dozen  surgeons  in  Great  Britain,  each  with  cases  reckoned  by 
hundreds,  can  speak  of  a  general  mortality  in  ovariotomy  scarcely 
exceeding  four  per  cent. 

Preparatory  Measures.  —  Before  the  performance  of  ovariotomy  atten- 
tion is  given  to  tlie  ixM-fecting  of  the  0])erative  environment,  and  to  the 
preparation  of  the  patient  for  operation. 


874  SYSTEM   OF  GYNAECOLOGY 

Pleasures,  special  to  ovariotomy  in  respect  to  operating  room  and 
furniture,  tlie  arrangement  of  assistants,  the  provision  of  instruments, 
and  so  forth,  are  to  be  discussed  here. 

Operating  Room.  —  For  ovariotomy  no  special  operating  room  is 
essential.  It  has  been  abundantly  proved  that  the  operation  may  be 
performed  with  as  great  success  in  the  general  operating  room  of  a  large 
hospital,  or  in  a  bedroom  of  a  private  dwelling,  as  in  special  rooms  elabo- 
rately fitted  for  the  purpose.  If  the  operating  theatre  is  kept  as  it  should 
be  for  operations  in  general,  it  is  suitable  for  the  performance  of  ovari- 
otomy. A  specially  prepared  theatre  is  a  luxury  rather  than  a  necessity 
—  a  saving  of  trouble  in  preparing  for  and  doing  of  the  operation  rather 
than  an  addition  to  its  safety.  Still  the  technique  is  easier,  and  therefore 
more  perfect  in  convenient  circumstances  ;  and  every  surgeon  would  desire 
to  perform  ovariotomy  in  a  room  specially  prepared  for  the  purpose,  with 
all  the  accessories  that  the  science  and  art  of  antiseptics  have  introduced, 
and  all  the  aids  Avhich  experience  in  the  operation  has  suggested. 

In  private  the  operation  is  usually  done  in  the  room  which  the 
patient  is  to  occupy  during  convalescence.  A  large  sunny  room  which 
can  be  easily  ventilated  should  be  selected.  A  bedroom  in  the  clean  and 
wholesome  condition  usually  found  in  houses  of  the  upper  and  middle 
classes  in  these  islands  requires  little  to  be  done  to  it.  If  it  be  deemed 
advisable  to  remove  carpets  or  curtains,  this  should  be  done  at  least 
two  clear  days  before  operation,  so  that  the  germ-laden  dust  may  have 
time  to  settle.  For  ventilation  a  fire  in  an  open  grate  should  be  kept 
burning,  even  in  warm  weather.  A  narrow  bedstead  with  spring  and 
horse-hair  mattress  should  be  used.  After  the  first  few  days  the  use  of 
two  beds,  one  for  the  day  and  another  for  the  night,  may  add  to  the 
patient's  comfort.  A  large  folding  screen  which  will  shield  the  patient 
from  glare  without  darkening  the  room  may  be  useful. 

Operating  Table.  —  Many  operating  tables  especially  suitable  for 
ovariotomy  have  been  devised.  A  simple  deal  board  on  trestles  does  per- 
fectly well.  For  private  work  a  portable  table  such  as  that  of  Mr.  Bowre- 
man  Jessett  is  convenient.  For  hospital  work  a  more  elaborate  table  is 
desirable.  I  have  designed  a  table  made  of  plated  steel-tubing  and  glass, 
which  can  at  once  be  raised  to  any  height,  and  made  suitable  for  the 
Trendelenburg,  or  any  other  posture.  A  reservoir,  hung  under  the  table 
well  away  from  the  surgeon's  feet  and  legs,  collects  ovarian  or  other 
fluids.  A  shoot  from  the  side  of  the  table  conducts  the  fluids  into  this 
receptacle  from  the  mackintosh  overlying  the  patient. 

The  patient's  limbs  should  bo  confined  during  operation,  and  jorovi- 
sion  should  be  made  for  this.  In  the  operating  table  described  this  is 
managed  by  a  broad  strap  of  webbing  passing  over  the  knees,  and  by 
wristlets  which  hold  the  patient's  arms  under  the  table.  But  a  piece  of 
strong  webbing  tied  over  the  knees  and  under  the  table  for  the  patient's 
legs,  and  a  strong  bandage  fixed  round  her  wrists  under  tlie  table,  do 
perfectly  well. 

The  table  is  covered  either  with  a  special  sterilised  mattress  or  a 


OVARIOTOMY  875 


folded  blanket.  For  certain  cases  it  is  necessary  to  adopt  measures  for 
the  application  of  artificial  heat,  and  some  device  for  this  purpose  should 
be  provided  with  every  operating  table.  Large  copper  or  aluminium 
reservoirs  filled  with  hot  water,  and  placed  under  the  patient  or  under 
the  table,  are  sometimes  used ;  such  vessels,  made  to  fit  the  table,  can 
easily  be  applied  under  the  glass  of  the  table  described.  If  long  tubing 
is  attached  to  entrance  and  exit  taps,  the  water  can  be  replaced  by 
fresh  hot  Avater  during  the  operation,  without  disturbing  the  operator  or 
assistants.  Hot-water  bottles  of  rubber  laid  around  the  patient's  body, 
and  between  and  by  the  sides  of  her  thighs,  serve  the  purpose  very  well. 
For  the  majority  of  casesnospecialapplicationofartificialheatisnecessary. 

Coverings  of  Patient. — The  best  clothing  for  the  patient  during 
operation  is  a  single  combination  suit,  completely  enveloping  limbs  and 
body,  and  open  down  the  front  of  the  abdomen.  Such  suits  made  of 
several  layers  of  fine  flannel,  or  of  fine  cotton  quilted  Avith  cotton  wool, 
may  be  sterilised  completely  without  injuring  their  fabric.  If  such  a 
suit  be  not  available,  thick  woollen  drawers  and  stockings,  and  a  thick 
woollen  jacket,  are  quite  suitable.  If  there  be  any  special  need  for  it, 
additional  security  against  loss  of  body  warmth  is  got  by  packing  cotton 
wool  under  the  drawers  and  jacket,  or  rolling  it  round  the  limbs,  and 
securing  it  with  a  bandage.  For  ordinary  hospital  work,  two  thick 
blankets  sewed  together  and  cut  at  the  sides  like  a  many-tailed  bandage 
may  be  used  as  a  wrap  for  the  patient  during  operation.  To  expose  the 
seat  of  operation  two  of  the  flaps  are  folded  back,  one  on  each  side  ;  the 
rest  of  the  body  remaining  covered. 

Over  all  is  laid  a  large  sheet  of  mackintosh  cloth,  in  which  an  oval  hole 
has  been  cut  large  enough  freely  to  expose  the  field  of  operation.  An 
opening  four  inches  broad  and  eight  inches  long  is  large  enough  for 
most  ovariotomies.  Around  this  opening  on  the  cutaneous  aspect  of  the 
cloth  is  spread  some  adhesive  material,  such  as  emplastrum  adhesivum ; 
this,  heated  before  operation,  serves  to  glue  the  mackintosh  to  the  parietes, 
and  so  prevent  soiling  of  clothes,  and  secures  isolation  of  the  part  to  be 
operated  upon.  The  mackintosh  also  prevents  loss  of  bodily  heat  by 
radiation,  and  keeps  away  from  the  wound  particles  of  wool,  cotton,  or 
other  dust  given  off  by  the  clothing. 

Prejxiration  of  Patient.  —  The  general  preparation  of  the  patient  in- 
cludes free  opening  of  the  bowels ;  it  is  better  to  do  this  by  gentle  purga- 
tion for  two  or  three  days  before  operation  than  by  a  single  sharp  purge 
the  night  before.  During  the  twenty-four  hours  preceding  operation  all 
food  should  be  either  liquid,  or  of  a  nature  to  leave  little  residue  in  the 
intestines.  The  last  meal  will  be  regulated  b}'  the  orders  of  the  anaes- 
thetist. Many  surgeons  give  the  patient  morphia  before  operation ;  a 
few  speak  highly  of  the  value  of  strychnia  given  hypodermically  as 
a  means  of  keeping  the  bowels  contracted  during  and  after  operation. 
A  thorough  cleansing  of  the  Avhole  body  in  a  bath  with  soap  should 
precede  operation. 

Locally  the  seat  of  operation  is  purified  in  the  manner  described 


876 


svsi'EJi  OF  gyx.f:cology 


under  '-Antiseptics"  (p.  270).  The  pubic  hair  is  shaved.  The  risk  of 
infection,  however,  lies  rather  in  the  numerous  and  large  hair-follicles  in 
this  region  than  in  the  hair ;  it  is  indeed  doubtful  if  this  region  is  ever 
rendered  perfectly  sterile.  Therefore  it  is  wise  at  and  after  the  operation 
to  use  active  antiseptics  on  the  skin  over  the  pubes.  A  good  plan  is  to 
rub  powdered  boric  acid  dissolved  in  carbolic  lotion  into  the  skin  in 
this  region.  This  plan  will  certainly  keep  the  skin  sweet  for  a  week; 
thereafter  the  risk  is  over. 

Arrangements  for  Operation.  — The  placing  of  the  table,  surgeon,  and 
assistants  is  shown  in  the  accompanying  diagram.  The  patient's  feet  are 
towards  the  window  or  chief  light.  The  surgeon  stands  on  the  patient's 
right ;  his  assistant — only  one  operating  assistant  is  necessary — opposite 


TABLE  WITH 
INSTRUMENTS 
B1LICATUBE9 


Fig.  212.  — Diagram  to  show  placing  of  table,  surgeon,  assistants,  nurse,  and  instruments 
in  ovariotomy.    {After  Doran.) 

to  him  on  the  patient's  left.  The  nurse  stands  behind  the  assistant,  takes 
sponges  from  his  hand,  cleanses  them,  and  returns  them  dry  as  they  are 
wanted.  The  instruments  lie  on  trays  covered  with  sterilised  water,  or 
in  antiseptic  solution,  close  to  the  surgeon's  right  hand.  The  surgeon 
should  help  himself  to  instruments  —  an  assistant  to  hand  them  imports 
another  risk  and  is  quite  superfluous.  A  swinging  tray,  attached  to  the 
table  on  which  the  instruments  are  placed,  which  can  be  brought  close  to 
the  seat  of  operation,  is  a  convenience  for  holding  the  insti'iuuents  which 
are  in  constant  use. 

Sponyea  and  Sponge-cloths. —  A  dozen  sponges  of  im(l()nl)ted  purity 
should  be  in  readiness.  These  should  be  assorted  as  follows  :  two  large 
flat  sponges,  two  medium  flat,  and  eight  round  of  various  sizes.  The 
sponges  should  ]je  of  the  flnest  Tui'k(sy  growth. 

Two  dozen  sponge-cloths  kept  in  warm  sterilised  or  antiseptic  solu- 
tion are  also  at  hand.  For  absorbing  fluids  and  blood,  for  covering 
extruded  bowels,  and  in  numerous  other  ways,  sponge-cloths  are  invalu- 
able.    They  are  laid  on  the  mackintosh  all  round  and  close  up  to  the 


OVARIOTOMY  877 

parietal  wound,  keeping  the  operating  field  aseptic  and  absorbing  any 
fluids  that  escape.  As  soon  as  a  sponge-cloth  is  soiled  the  assistant 
quietly  replaces  it  by  a  fresh  one.  As  a  rule,  sponge-cloths  only  are 
used  during  the  making  of  the  parietal  wound,  and  many  operations  are 
finished  without  the  use  of  a  single  sponge. 

Artificial  sponges,  made  of  pads  of  absorbent  material  in  gauze  bags, 
are  used  by  some  surgeons.  They  do  not  absorb  so  well  as  natural 
sponges ;  and  they  are  no  more  safe,  if  due  care  be  observed  in  prepar- 
ing the  natural  ones.  If  gelatinous  fluid  has  to  be  removed  from  the 
cavity  of  the  abdomen  natural  sponges  are  almost  essential. 

Instruments.  —  The  surgical  armamentarium  may  conveniently  be  as 
follows :  — 

One  scalpel ;  one  scissors,  dissecting,  elbowed ;  one  scissors  for 
sutures  and  pedicle,  flat ;  twelve  haemostatic  pressure-forceps,  small ; 
six  haemostatic  pressure-forceps,  medium;  two  T-shaped  forceps;  four 
cyst-forceps  —  large  —  straight ;   four  cyst-forceps  —  large  —  bent ;  one 


Fig.  213.  — Tail's  modification  of  Wells'  catoh-forceps. 

forceps  for  placing  pedicle  ligature;  one  cyst-trocar  —  Tait's  large;  one 
cyst-trocar  —  Wells'  —  Fitch's  dome  ;  one  suture-needle  (several  sizes 
of  needle)  ;  one  reel-stand  with  silk  ligatures ;  six  glass  drainage  tubes 
—  assorted. 

With  these  instruments  most  ovariotomies  may  satisfactorily  be 
performed.  In  reserve,  however,  and  sterilised  ready  for  use,  should 
be  the  following :  — 

Aspiration  apparatus  ;  intestinal  needles ;  Lane's  intestinal  clamps ; 
cautery  irons,  or  thermo-cautery ;  a  second  dozen  of  pressure-forceps ; 
abdominal  retractors ;  means  of  providing  artificial  light  with  mirror, 
electric  apparatus,  or  otherwise. 

The  instruments  are  arranged  in  trays  containing  warm  sterilised 
water  or  carbolic  lotion.  They  should  be  arranged  in  groups,  and  so 
placed  that  the  surgeon  can  put  his  hand  in  a  moment  on  the  instrument 
he  wants.     An  instrument  after  use  is  replaced  in  its  tray.     The  tro- 


878 


SYSTEM   OF  GYNECOLOGY 


cars,  Tvitli  tubing  attached,  are  placed  ia  a  special  large  basin.  The 
reel-holder,  containing  at  least  four  sizes  of  Chinese  silk,  stands  by 
itself;  the  ligatures  are  pulled  out  and  cut  off  by  the  surgeon  himself 
as  they  are  ^\"anted. 

Some  of  the  most  important  instruments  may  be  briefly  described. 
Of  forceps,  the  best  and  most  generally  used  is  that  known  by  Spencer 
Wells'  name  (Fig.  21 3).  Tait  has,  I  think,  improved  the  model  by  making 
the  blades  shorter  and  more  pointed,  thus  giving  more  power  in  grasp, 
and  permitting  the  ligature  to  slip  more  easily  over  the  point.  In  these 
instruments  the  blades  are  serrated  transversely  to  their  length,  and  the 

tissues   caught  in  them  are  thus 

flattened  out  and  Avrinkled,  while 

lateral  traction  is  liable  to  cause 

For  some  years  past  I  have 
been  using  forceps  of  the  same 
size  and  shape,  in  which  the 
serrations  are  carried  round  the 
blades  parallel  to  their  margins 
instead  of  across  them.  The 
tissues  are  thus  sharply  compressed  along  two  lines,  and  an  uncom- 
pressed bulb  of  tissue  lies  in  the  centre  of  the  blades  which  effectually 
prevents  slipping,  and  serves  to  hold  the  ligature. 


Fig.  214.  —  Catch-forceps.    (Author's  model.) 


■Blades  of  author's  forceps. 


As  haemostatic  agents  these  forceps  are,  in  my  opinion,  superior  to 
those  with  serrated  flat  blades  ;  they  sharply  com- 
press, almost  divide,  any  vessel  included :  rarely 
has  any  ligature  to  be  applied  to  a  bleeding  point 
on  which  they  have  been  i)laced.     They  are  made  P'«-  216.- Author's  peritoneal 

„     .  ■;     .  ,„.    ^  Ti       ,     •        /IT       fn /.\  catch-forceps. 

in  all  Sizes  and  shapes.  The  smallest  size  (hig.  2l<)), 

with  one  biting  edge  and  a  sharp  point,  is  used  for  picking  up  the 


OVARIOTOMY 


879 


peritoneum ;  of  larger  size  they  are  useful  in  seizing  the  slippery  cyst- 
wall,  and  in  holding  omentum  that  has  been  stripped.     The  largest 


Fig.  217  — Large  pressure-forceps  ;  straight.     (Author's  model.) 

size  is  convenient  for  grasping  broad  masses  of  tissue,  and  is  made 
straight,  T-shaped,  and  bent  at  various  angles.     These  instruments  are 


Fig.  219. 
■Wells'  larpe  forceps,  bent  (Fig.  218) ;  and  Straight  (Fig.  219). 

all  made  on  the  Wells'  pattern  as  regards  handles  and  blades ;  the  only 
variation  is  in  the  form  of  the  biting  surfaces  of  the  blades. 

The  large  forceps  of  Wells,  straight  and  bent  (Figs.  219  and  218) ;  the 


88o  SYSTEM  OF  GYNECOLOGY 

same  instruments  with  tlie  blades  at  right  angles  (Fig.  220)  and  T-shaped 
(Thornton)  (Fig.  221)  are  in  universal  use  and  are  highly  appreciated; 


Fig.  220.  — Wells'  large  pressure-forceps,  rectangular  blades  ;  \  size. 

their  handles  are  similarly  shaped ;  they  all  have  the  rack  catch,  which 
is  quickly  applied  and  released,  and  they  are  very  powerful.     A  clamp 


Fio,  221.  —Thornton's  T-shaped  pressure-forcops  ;  J  size. 

forceps  with  screw  compression  used  by  Wells  (Fig.  222)  may  occasion- 
ally be  found  useful. 

For  grasping  and  dragging  out  the  cyst,  Nelaton's  special  forceps 
(Tig.  223)  have  biuMi  much  employed  and  found  very  valuable.  The 
spikes  in  the  blades  are  supposed  to  add  to  their  holding  power ;  I  think 
they  tend  to  lacerate  the  parts. 

Excellent  cyst-forceps  are  those  of  tSydney  Jones  (Fig.  224),  but  as 


OVARIOTOMY 


88i 


cyst-forceps  I  consider  those  already  described  with  doiible   parallel 
serration  to  be  the  best. 

On  cutting  instruments  little  need  be  said.     I  have  used  the  same 


Fig.  222.  — Wells'  olainp-forceps  ;  §  size. 


scalpel  in  several  hundreds  of  operations ;   it  has  never  been  to  the 
instrument  maker,  but  is  sharpened  by  a  few  strokes  on  steel  or  hone 


Fig.  223.  —  Nelaton's  cyst-forceps;  \  size. 


before  every  operation.    The  scissors  which  I  i;se  have  the  same  handles 
as  catch-forceps ;  their  blades  are  bent  a  little,  rounded,  and  rather  sharp 


Fig.  224. — Sydney  Jones'  cyst-forceps. 


pointed.  They  are  useful  in  delicate  as  Avell  as  in  coarse  work.  Separ 
rate  scissors,  curved  on  the  flat,  should  be  iised  in  the  division  of  liga- 
tures and  sutures. 

The  ligatures  used  in  ovariotomy  are  most  conveniently  made  of  silk  ; 
Chinese  twist  in  four  assorted  sizes,  from  the  smallest  to  the  largest,  will 

^3l 


882 


SYSTEM  OF  GYNECOLOGY 


suffice.     These  ligatures  must  be  absolutely  aseptic.     For  keeping  the 
ligatures  I  can  confidently  recommend  my  own  holder  (Pig.  226).     It  is 


Fig.  225.  — -Author's  scissors. 


composed  of  a  stand  with  weighted  base  made  of  metal  which  will  not 
rust,  and  which  can  be  removed  and  placed  in  boiling  soda  solution ;  and 
of  a  vulcanite  case  with  screw  cap,  which  is  air-tight.    If  the  stand  with 


Fio.  22G.  —  Author's  reel  holder;  \  size. 


the  reels  is  boiled  now  and  again,  and  1-20  carbolic  lotion  poured  into  it 
for  every  operation  and  decanted  afterwards,  tlie  silk,  thus  kept  in  car- 
Vjolic  vapour  and  away  from  the  possibility  of  contamination  by  air,  may 
always  be  trusted. 

These  instruments  are  in  constant  use  throughout  the  operation. 
Special  instruments  required  in  special  parts  of  the  operation  are  tap- 
ping trocars,  jjedicle  needles  or  forceps,  drainage  tubes,  and  needles  for 
placing  the  sutures  in  the  parietal  wound. 


OVARIOTOMY 


883 


Of  tapping  trocars  the  best  known  is  Spencer  Wells'  (Fig.  227),  which 
contains  an  inner  blunt  tube  in  an  outer  cutting  tube,  and  two  spring 
clasps  with  sharp  teeth  to  hold  the  cyst  wall.     A  very  useful  tube  iu 


Fig.  227.  —  Wells'  large  cyst-trocar  ;  \  size. 


Fig.  229.  —  Tait's  cyst-trocar  ;  J  size. 


smaller  size  was  also  designed  by  Wells,  with  Fitch's  safety  dome  which 
can  be  pushed  beyond  the  cutting  point  (Fig.  228). 

The  trocar  which  I  like  best  is  that  of  Lawson  Tait  (Fig.  229).     It 
does  not  cut  at  all ;  it  pierces  and  dilates.     It  is  a  simple  piece  of  metal 


884  SYSTEM   OF  GYNECOLOGY 


tubing,  bluntly  conical,  and  bent  to  a  right  angle  in  tlie  shaft.  It  can 
he  had  of  all  sizes ;  the  largest  size  is  rarely  too  large. 

To  the  trocar  is  attached  a  piece  of  thick  rubber  tubing  of  the  same 
calibre  as  the  trocar.  The  tubing  must  have  thick  walls  to  prevent  the 
chance  of  its  becoming  blocked  by  kinking. 

For  carrying  the  ligature  through  the  pedicle  various  needles  are  in 


Fig.  230.  —  Sj-dney  Jones'  pedicle  needle. 


use  (Figs.  230,  231).     Any  needle  will  do  if  it  is  curved,  handled,  and 
blunt.     An  aneurysm  needle  does  very  well.     I  employ  a  forceps  with 


Fig.  231.  —  Wells'  pedicle  needle. 


blades  and  points  like  those  of  Lister's  sinus  forceps,  but  bent  (Fig.  232). 
The  closed  instrument  is  pushed  through  the  pedicle ;  the  blades  are 


Fig.  232.  — Author's  forceps  for  placing  ligature  on  pedicle. 


then  opened  and  made  to  grasp  the  ligature  which  is  placed  during 
withdrawal. 

Of   drainage  tubes  the   original  ones  of  Keith  (Fig.  233),  of  the 


Fig.  %','■'!.  ~  Keith's  fe'lass  drainage  tube  ;  \  size. 

same  diameter  throughout,  with  a  collar  and  with  a  few  perforations 
near  the  point,  are  still  the  best. 


OVARIOTOMY 


For  the  drainage  of  large  opened  np  spaces  a  drainage  tube,  shaped 
like  a  test-tube,  with  perforations  nearly  all  the  way  up,  is  sometimes 
of  advantage  (Fig.  234).     The  sharp  rim  of  a  Keith's  tube  must  not  be 


Fifi.  2U.  —  Glass  drainag-e  tube  ;  \  size. 

pressed  down  on  the  rectum  or  other  part  of  bowel  for  any  long  time, 
as  it  may  cause  perforation. 

A  sponge-holder,  with  blades  long  enough  to  reach  to  the  loins,  should 
be  amongst  the  instruments  in  readiness  (Fig.  235). 


Fig.  23.5.  —  Sponge-holder  ;  I  size. 


In  placing  the  sutures  in  the  parietal  wound  most  surgeons  have 
special  methods  of  their  own.     The  instrument  shown  (Fig.  236)  does 


Fig.  2.'?Ci.  —  Author's  suture  instrument ;  J  size. 

equally  well  for  silk  or  for  silk-worm  gut.  The  silk,  preferably  plaited, 
is  held  on  its  reel  in  a  cavity  in  the  handle,  which  is  tilled  with  antiseptic 
solution.  If  silk-worm  gut  (in  my  opinion  the  best  suture  material)  be 
used  the  reel  is  discarded,  and  each  suture  is  passed  into  the  eye  of  the 
needle  after  the  needle  has  been  carried  through  both  sides  of  the 
incision :  the  sut\ire  is  thus  placed  on  its  withdrawal.  The  needle  is  on 
Hagedorn's  principle,  except  that  the  eye  is  at  the  point.  Hagedorn's 
needles,  used  with  his  holder,  serve  the  purpose  admirably.  Some  sur- 
geons use  ordinary  glover's  or  similar  needles. 


8S6  SYSTEM   OF  GYNECOLOGY 

The  Operation.  —  The  patient  being  anaesthetised,  and  sponge-cloths 
wrung  out  of  warm  lotion  having  been  laid  around  the  field  of  operation 
on  the  mackintosh,  the  actual  operation  is  begun  by  — 

The  parietal  incision,  which  is  made  in  the  middle  line,  and  lies,  as  a 
rule,  midway  between  umbilicus  and  pubes.  If  the  tumour  be  large  the 
incision  lies  nearer  to  the  pubes  than  to  the  umbilicus.  It  is  not  advisa- 
ble to  go  closer  to  the  pubes  than  two  inches,  on  account  of  the  prox- 
imity of  the  bladder  ;  if  it  be  necessary  to  enlarge  the  opening  the  wound 
is  extended  upwards.  The  first  incision  will  vary  from  two  to  five  inches 
in  length,  according  to  the  thickness  of  the  parietes  and  the  amount  of 
solid  matter  in  the  tumour.  In  a  few  cases  it  may  have  to  be  enlarged 
to  six  or  eight  inches. 

The  first  cut  usually  divides  the  skin  and  fatty  tissue  down  to  the 
fibrous  aponeurosis.  In  very  stout  persons  the  fatty  layer  may  be  several 
inches  in  thickness,  and  this  may  be  increased  in  thickness  by  oedema. 
In  very  thin  persons,  with  distended  abdomen,  the  subcutaneous  fat  may 
be  absent.  Catch-forceps  are  placed  on  bleeding  points :  these  may  be 
removed  as  soon  as  the  cavity  is  opened ;  in  a  few  seconds  haemostasis 
will  be  complete  and  permanent,  and  ligatures  will  be  unnecessary. 

The  fibrous  aponeurosis  is  next  divided  as  nearly  as  possible  in  the 
linea  alba.  A  glance  at  the  arrangement  of  the  fibres  will  often,  by  their 
symmetrical  arrangement  on  the  two  sides,  show  the  exact  middle  line ; 
but  frequently  the  linea  alba  is  not  hit  off,  or  not  divided  at  all,  but  one 
or  other  sheath  of  the  rectus  is  entered.  In  persons  with  powerful 
recti,  and  not  very  distended  parietes,  the  linea  alba  may  be  no  more 
than  a  thin  fibrous  septum ;  in  women  with  thin  or  distended  parietes 
the  linea  alba  may  be  broad,  and  there  will  then  be  no  difficulty  in 
avoiding  the  recti.  But  to  expose  either  or  both  muscles  does  no  harm  ; 
indeed,  some  surgeons  say  that  to  expose  muscle  and  bring  it  into  the 
line  of  union  is  a  distinct  advantage,  as  it  helps  to  prevent  ventral  hernia. 
There  is  certainly  no  advantage  in  being  far  from  the  middle  line ;  if  the 
sheath  be  opened  it  should  be  close  to  the  linea  alba.  A  small  cut  is 
made  with  the  scalpel  through  the  thick  aponeurosis;  a  glance  will 
show  whether  it  is  far  from  the  middle  line,  and  on  which  side :  it  is 
then  extended  upwards  and  downwards  towards  the  middle.  Below 
the  falciform  edge,  where  most  operations  are  done,  there  is  no  more 
aponeurosis  to  divide;  above  this  level  the  wall  of  the  sheath  of  the 
rectus  remains  to  be  divided. 

The  subperitoneal  fatty  and  areolar  tissue  is  now  exposed.  It  is 
naturally  very  loose  and  elastic,  and  it  can  readily  be  teased  apart  so 
as  to  expose  the  underlying  peritoneum.  Occasionally  it  is  very  sparse 
in  amount;  sometimes  it  is  thickened  and  hardened  by  inflammation, 
and  firmly  adherent  both  to  peritoneum  and  to  muscle.  The  fat  is 
pushed  to  one  side  and  the  other,  and  a  minute  portion  of  peritoneum  is 
cauglit  up  in  the  fine  peritoneal  catch-forceps  and  pulled  to  the  surface. 
A  second  forceps  is  placed  close  to  the  first,  by  its  side ;  the  minutest 
grip  suffices  to  give  a  holding.     Between  the  two  pairs  of  forceps  the 


OVARIOTOMY 


raised  fold  is  gently  sawed  through  by  a  knife,  air  rushes  in,  the  bowels 
fall  back,  and  the  opening  is  enlarged  to  a  size  sufficient  to  admit  the 
forefinger.  The  left  forefinger  is  introduced  through  the  opening,  and 
the  peritoneum  divided  on  it  upwards  and  downwards  to  the  full  extent 
of  the  outer  incision  by  scissors.  Any  small  vessel  which  bleeds  is  at 
once  seized  in  catch-forceps,  which  are  left  hanging  for  a  few  seconds, 
or  till  after  the  cyst  is  emptied. 

In  ovariotomy  the  incision  has  rarely  to  be  increased  beyond  a  length 
of  four  or  five  inches.  This  is  best  done  by  scissors  dividing  the  whole 
thickness  of  the  wall  at  each  stroke.  If  the  incision  has  to  be  carried 
above  the  umbilicus  it  should  be  carried  to  the  left  of  it ;  this  is  done  to 
avoid  the  round  ligament  of  the  liver  and  the  thin  tissues,  not  suitable 
for  holding  sutures,  in  the  umbilicus  itself. 

When  the  peritoneum  is  adherent  to  the  underlying  tumour  its 
separation  requires  some  judgment  and  experience.  It  has  frequently 
happened  that  peritoneum  has  been  stripped  from  parietes  in  the  belief 
that  tumour  was  being  stripped  froin  peritoneum.  An  inflamed  and 
thickened  peritoneum  is  usually  vascular  and  somewhat  friable. 

Emptying  and  delivering  the  Cyst  —  Separation  of  Adhesions.  —  The 
tumour  being  exposed  and  found  suitable  for  removal,  it  is  tapped 
at  once.  It  is  unnecessary  to  introduce  fingers,  still  less  the  hand,  un- 
less the  diagnosis  be  doubtful.  Adhesions  are  best  left  till  the  cyst  is 
emptied. 

A.  point  for  inserting  the  trocar  should  be  selected  in  a  large  and 
thick-walled  cyst ;  small  thin  cysts  and  the  sulci  between  them  sliould 
specially  be  avoided.  Tait's  large  trocar  is,  as  a  rule,  the  most  con- 
venient. If  the  cyst-wall  be  thick  a  slight  cut  with  a  scalpel  through 
the  outer  layers  facilitates  the  introduction  of  the  blunt  point  of  the 
trocar.  The  trocar  is  plunged  in  with  the  left  hand,  and  fluid  at  once 
flows  into  the  receiver  through  the  rubber  tubing.  Almost  simultaneously 
the  cyst-wall  below  the  trocar  is  grasped  in  cyst-forceps  held  in  the  right 
hand,  and  is  pulled  to  the  surface.  Deft  manipulation  will  always  avoid 
the  escape  of  fluid  into  the  peritoneal  cavity,  and  will  bring  the  rapidly 
collapsing  cyst-wall  outside  the  parietal  incision.  The  parietes  are  not 
pressed  back  on  the  cyst;  rather  is  the  cyst  pulled  outwards  and  on  to 
the  parietes.  A  second  pair  of  forceps,  placed  on  the  cyst  above  the 
trocar,  suffices  to  hold  the  opening  in  the  cyst  outside  the  wound  during 
the  emptying,  and  perhaps  to  deliver  the  whole  tumour. 

Delivery  is  prevented  by  the  presence  of  semi-solid  polycystic  material 
in  the  growth,  and  by  adhesions.  Secondary  cysts  nuiy  be  emptied  one 
after  the  other  by  pushing  the  trocar  into  them.  If  they  are  very  closely 
set  and  very  numerous,  the  trocar  is  now  removed,  and  two  fingers  of 
the  right  hand  are  carried  through  the  opening  to  break  the  numerous 
small  cysts  into  the  large  one ;  or  the  openings  in  parietes  and  cysts 
may  be  enlarged  and  the  whole  hand  introduced  to  break  up  the  cysts. 
Meanwhile  the  assistant,  holding  the  large  catch-forceps,  keeps  the  C3'st 
opening  well  outside  the  parietal  opening,  and  turns  it  so  that  any  fluid 


SYSTEM  OF  GYNECOLOGY 


escaping  shall  run  over  the  mackintosh  into  the  receptacle  provided.  If 
the  fluid  be  very  foul  a  sponge-cloth  or  two  laid  around  the  parietal  open- 
ing will  provide  additional  security  against  its  entering  the  abdominal 
cavity.  When  the  whole  of  the  semi-solid  matter  has  been  broken  up  tiie 
hand  is  removed,  and  the  contents  are  squeezed  out  by  pressure  on  the 
parietes :  these  run  over  the  mackintosh  into  the  vessel  under  the  table. 

The  cj^st  may  now  be  delivered  through  the  parietal  opening.  This 
is  done  by  traction  on  the  attached  forceps,  one  pair  after  another  being 
placed  as  the  tumour  comes  out.  If  the  walls  are  very  friable  the  largest 
forceps,  with  slight  compression,  should  be  employed.  The  advantages 
of  my  instruments,  which  hold  very  firmly,  and  neither  pierce  nor  cut, 
are  most  conspicuous  in  the  handling  of  cysts  with  friable  walls. 

If  delivery  is  prevented  by  adhesions  these  are  now  dealt  with.  If 
the  cyst  has  not  been  completely  emptied,  and  if  there  is  any  risk  of  the 
fluid  escaping  into  the  cavity,  the  opening  in  the  cyst  is  closed  by  press- 
ure-forceps suitably  placed  around  the  opening.  Adhesions,  wherever  pos- 
sible, are  separated  within  sight ;  but  many  adhesions,  such  as  those  to  the 
liver,  must  be  separated  far  from  vision  by  fingers.  In  the  separation  of 
fine,  soft,  or  recently  formed  adhesions,  the  hand  or  fingers  working  their 
way  over  the  cyst-wall  easily  succeed.  Such  adhesions  bleed  very  little, 
and  the  bleeding  soon  ceases.  The  use  of  a  sponge  is  often  advisable. 
The  adherent  organ  is  sj)onged  away  from  the  cyst- wall ;  if  there  is  any 
bleeding  the  sponge  is  left  on  the  detached  organ,  and  removed  later 
with  the  blood  which  it  will  have  absorbed.  Firm  adhesions  must  be 
dealt  with  more  deliberately.  Sometimes  they  may  be  peeled  off  by  the 
fingers,  or  fingers  aided  by  sponging ;  each  strip  of  adhesion  is  examined 
for  bleeding  after  detachment,  and  a  forceps  placed  on  it.  Old,  firm,  and 
fibrous  adhesions  are  divided  and  tied  on  the  distal  side  ;  a  catch-forceps 
is  left  on  the  tumour  side,  and  removed  with  the  tumour.  Omental 
adhesions  are  perhaps  the  most  common ;  they  can  usually  be  peeled  off, 
but  nearly  always  demand  forcipressure.  Coils  of  intestine  adherent  in 
the  sulci  between  cysts  require  very  careful  handling.  It  is  better  always 
to  detach  a  piece  of  cyst-wall  witli  the  gut  than  to  injure  the  latter  by 
tearing,  or  by  denuding  it  of  its  outer  coats. 

Forceps  holding  bleeding  points  in  adliesions  are,  wherever  possible, 
brought  outside  the  parietal  opening,  and  laid  on  and  covered  up  by 
sponge-cloths. 

Where  the  adhesions  lie  deeply  large  forceps  are  attached  the  handles 
of  which  remain  outside ;  and  sponges  in  such  cases  are  packed  inside  the 
abdomen  over  the  rawed  surfaces.  When  the  tumour  is  delivered  and 
cut  away  the  forceps  are  removed  one  after  another ;  and  the  tissues 
caught  in  their  blades  are  closely  examined.  In  most  cases  where  for- 
ceps have  V)een  compressing  bleeding  vessels  hamostasis  will  be  perfect, 
and  the  adhesion  may  be  allowed  to  slip  inside.  Where  there  is  any 
sign  of  bleeding  or  of  oozing,  a  silk  ligature  is  placed  before  the  adhesion 
is  returned.  In  bad  cases  from  a  dozen  to  two  dozen  forceps  may  be 
left  on,  each  holding  its  own  bleeding  point ;  yet  when  they  come  to  be 


OVARIOTOMY 


removed  a  few  minutes  later,  not  a  single  ligature  may  have  to  be 
applied. 

Treatment  of  the  Pedicle.  —  The  pedicle  is  now  almost  universally 
secured  by  ligature,  the  stump  being  dropped  into  the  abdominal  cavity. 
The  only  method  which  for  safety  can  compete  with  intraperitoneal 
ligature  is  that  of  Thomas  Keith  by  clamp  and  cautery.  As,  however, 
this  is  more  troublesome  and  no  more  safe  than  the  method  by  ligature, 
the  latter  alone  Avill  be  described. 

The  material  which  is  most  convenient  for  ligation  is  the  silk  thread 
known  as  "  Chinese  twist."  Silk  can  be  sterilised  easily  and  satis- 
factorily by  boiling.  It  does  not  swell,  and  it  holds  firmly  the  grip 
which  we  make  it  take.  It  becomes  quietly  encapsuled,  remaining 
quiescent  in  its  bed,  and  is  slowly  absorbed  in  the  course  of  a  few 
months. 

Various  thicknesses  of  silk  are  used  according  to  the  size  and  the 
vascularity  of  the  pedicle.  By  compressing  the  pedicle  along  the  line 
of  ligature  with  strong  forceps,  the  chief  necessity  for  using  very  thick 
silk  —  to  bear  a  strong  strain  in  tightening  —  is  done  away  with.  Silk 
of  medium  thickness  will  easily  check  the  bleeding  if  the  fibrous  tissues 
which  surround  the  vessels  and  protect  them  from  compression  are  first 
squeezed  by  pressure-forceps.  The  silk  should  always  be  strong  enough 
to  bear  the  strain  of  hands  of  moderate  strength,  but  need  not  be  so 
strong  that  it  cannot  be  broken.  It  is  better  to  tie  the  pedicle  in  several 
sections  with  silk  of  moderate  thickness  than  to  tie  in  one  or  even  two 
masses  with  very  thick  silk.  In  every  case,  if  only  to  prevent  slipping, 
it  is  wise  to  use  a  transfixing  ligature. 

To  carry  the  ligature  through  the  pedicle  a  blunt  instrument  should 
be  used,  so  as  to  prevent  the  possibility  of  wounding  any  of  the  thin- 
walled  vessels.  The  blunt  needles  of  Sydney  Jones  (Fig.  230),  or  of 
Spencer  Wells  (Fig.  231),  serve  the  purpose  admirably.  An  aneurysm 
needle,  if  it  has  a  long  curve,  does  very  well.  I  use  a  curved  forceps 
with  blades  like  a  sinus  forceps  (Fig.  232) ;  this  is  pushed  through  the 
pedicle  at  the  points  selected :  its  blades  are  opened  after  being  passed 
through,  and  the  ligature  is  caught  in  them  and  placed  during  AvithdraAval. 
All  trouble  of  threading  and  unthreading  is  thus  done  away  with,  and  a 
series  of  ligatures  can  be  placed  with  great  rapidity  and  ease. 

If  a  simple  transfixing  ligature,  securing  the  pedicle  in  two  sections, 
be  used,  no  method  is  superior  to  that  of  Lawson 
Tait  by  the  Staffordshire  knot  (Fig.  237).  If 
the  forceps  be  used  the  ligature  is  placed  with 
great  ease.  Firstly,  the  forceps  is  passed  through 
the  pedicle ;  then  the  silk  is  placed  below  it 
around  the  whole  pedicle ;  then  the  two  free 
ends  are  caught  between  the  opened  blades  and  Fio.  28t.— Tait'sSuirordshiro 
withdrawn.     One  end  of  the  ligature  is  placed 

above  the  encircling  loop,  and  another  below.    The  two  ends  are  pulled 
tightly  by  the  right  hand,  while  the  finger  and  thumb  of  the  left  hand 


890 


SyST£J/  OF  GYNAECOLOGY 


Fig.  238. — Triple   interlocking-  ligatm-e  ; 
threads  Inserted,  loops  di^^ded. 


compress  the  line  of  ligature  ;  the  knot  is  cast  and  tied  in  the  ordinary 
way.     If  a  needle  be  used  to  carry  the  ligature  through,  the  loop  is 

raised  over  the  tumour  to  the  side  of 
entrance,  and  the  tAvo  free  ends,  one 
above  and  one  below  the  loop,  are  tied 
as  described. 

If  the  pedicle  be  a  large  one  it  may 
conveniently  be  tied  in  three  or  more 
sections.  The  ligatures  should  always  be 
made  to  interlock,  so  that  the  whole  mass 
is  kept  together,  and  there  is  no  down- 
ward splitting  with  possible  injury  to 
delicate  vessels.  With  the  pedicle-forceps 
a  series  of  ligatures  may  be  very  rapidly  and  easily  placed  in  one  long 
thread  (Figs.  238,  239,  240).  Two,  three,  or  four  loops  are  pulled  through 
as  we  desire  to  place  three,  four,  or  five 
ligatures ;  the  loops  are  divided,  and  the 
ligatures  then  lie  ready  for  tying.  The 
middle  ligature  is  tied  first ;  and  before  a 
ligature  is  tied  the  ligature  on  each  side 
should  be  looped  in  it.  With  a  properly 
placed  interlocking  or  chain  ligature,  the 
largest  pedicle  may  be  compressed  into 
wonderfully  small  bulk.  Compression  by 
large  forceps  along  the  line  of  ligature 
will  materially  facilitate  the  tightening. 

While  the  ligatures  are  being  tied  there  should  be  no  traction  on  the 
pedicle  by  the  weight  of  the  tumour,  or  otherwise.    In  vascular  or  fleshy 

pedicles  it  is  often  good  practice  to  hold  the 
ends  of  the  ligature,  and  to  keep  tightening 
it  while  the  assistant  cuts  the  tumour  away ; 
the  same  purpose  is  served  by  forcipressure. 
When  the  ligatures  are  tied,  and  the  tumour 
is  cut  away,  a  final  examination  of  the  stump 
and  ligatures  is  made,  and  if  all  be  secure 
the  pedicle  may  be  let  slip  'into  the  cavity.  If  there  is  sponging  or 
further  manipulation  to  be  carried  out,  I  usually  place  a  medium-sized 
forceps  on  the  tissues  in  the  middle  of  the  stump,  and  leave  it  there  till 
the  end  of  the  operation,  when  a  final  glimpse  is  given  to  it  to  make 
certain  that  all  is  secure. 

In  phicing  the  ligature  there  is  no  advantage  in  getting  deeply  inside 
tlie  abdomen  or  close  to  the  uterus.  The  ligature  should  be  about  half 
an  inch  away  from  the  tumour,  and  division  is  made  by  knife  or  scissors 
just  free  of  tumour  tissue.  No  doubt  tumour  tissue  has  often  been  left 
behind  in  the  stump,  yet  it  is  a  significant  fact  that  no  case  of  recurrence 
of  ovarian  tumour  on  the  side  of  removal  has  yet  l)een  recorded. 

In  cases  of  torsion  of  the  jjcdicle  I  ];)lace  the  ligature  at  the  site  of 


Fig.  239.  —  Triple  interlocking'  ligature; 
threads  interlocked  ready  for  tying. 


Fig.  '240. — Triiileintcrlockingligature  : 
threads  tied. 


OVARIOTOMY  891 


greatest  twisting,  and  do  not  undo  the  twist.  The  ligature  is  thus  made 
to  complete  what  nature  has  begun.  In  cases  of  large  fleshy  pedicles  a 
flap  of  peritoneum  may  be  left  to  cover  the  raw  surface,  and  so  serve  to 
minimise  the  risk  of  obstruction  from  intestine  getting  adherent  to  it. 
It  can  easily  be  fixed  over  the  stump  by  a  continuous  suture  of  fine  silk. 

When  the  pedicle  is  secured  the  alternate  ovary  should  be  examined. 
If  there  be  any  sign  of  disease  it  also  should  be  removed. 

Tlie  "■  Toilet  of  the  Peritoneum."  —  The  wound  should  not  be  closed 
until  all  foreign  matter  —  such  as  blood,  ovarian  or  ascitic  fluid,  or  pus 
—  has  been  removed  from  the  abdominal  cavity.  In  most  cases,  after 
delivery  of  the  tumour  and  before  division  of  the  pedicle,  a  sponge  will 
have  been  placed  inside  the  abdomen  under  the  parietal  wound.  This 
sponge  will  have  gathered  to  itself  any  free  fluid  that  may  lie  in  the 
lower  pelvis,  and  its  contents  on  removal  after  ligature  of  the  pedicle 
will  be  some  guide  to  the  amount  of  fluid  present.  A  sponge  in  a  long 
sponge-holder  (Fig.  235)  is  dipped  into  the  pelvis  behind  the  uterus. 
If  it  return  dry,  or  nearly  so,  no  further  sponging  is  necessary.  Then 
the  sponge  is  carried  successively  into  each  lumbar  hollow  over  the 
kidney  to  make  certain  that  no  fluids  have  gravitated  thither. 

If  the  fluid  be  present  in  moderate  amount  it  is  removed  by  successive 
introductions  of  sponges.  Each  saturated  sponge  is  squeezed  dry,  cleansed 
in  sterilised  soda  solution,  placed  in  hot  carbolic  lotion,  again  squeezed 
dry,  and  returned  to  the  surgeon,  who  picks  it  up  in  the  sponge-holder 
and  reintroduces  it.  Blood  in  the  presence  of  ascitic  fluid  clots  at  once ; 
and  wiping  of  surfaces,  or  even  a  little  friction  may  be  necessary  to  re- 
move it.  Glairy,  thick  ovarian  fluid  is  not  readily  mopped  up  ;  rotation 
of  the  sponge  helps  in  its  removal.  If,  by  mischance,  pus  have  escaped 
into  the  cavity,  irrigation  is,  I  think,  always  advisable. 

Irrigation  is  to  be  used  when  there  has  been  much  wounding  of 
peritoneal  surfaces  with  escape  of  blood ;  or  where  pus  or  thick  ovarian 
fluid  has  escaped  into  the  peritoneal  cavity.  This  is  done  by  pouring 
into  the  cavity  some  unirritating  sterile  fluid,  and  literally  washing  the 
bowels  and  peritoneum  in  it.  Of  all  fluids,  for  this  purpose  the  least 
irritating  is,  in  my  experience,  a  solution  of  Barff's  boroglyceride  of  the 
strength  of  half  an  ounce  to  the  pint  of  water.  Saline  solution  and 
simply  sterilised  Avater  may  safely  be  used,  but  these  cause  more 
injury  to  the  delicate  endothelium  than  boroglyceride.  The  fluid 
should  be  at  a  temperature  of  100°  F.,  or  even  a  few  degrees  warmer, 
The  solution  may  be  poured  in  out  of  a  jug  while  the  edges  of  the  parie. 
tal  wound  are  dragged  forwards.  The  fingers  then  freely  move  the 
intestines  about  in  the  fluid,  washing  them,  disturbing  clot  and  breaking 
it  up.  By  depressing  the  parietes  the  fluid  is  permitted  to  flow  out.  and 
is  guided  over  the  mackintosh  into  the  vessel  provided  for  its  reception. 
I  prefer  always  to  use  irrigation,  the  reservoir  being  raised  from  three  to 
six  feet  above  the  patient,  according  to  the  cohesiveness  of  the  materials 
to  be  removed.  A  specially  devised  glass  tube  with  perforated  bulbous 
ends  is  attached  to  the  rubber  coming  from  the  irrigator;    and  this, 


S92  SYSTEM   OF  GYNECOLOGY 

throwing  out  numerous  jets  of  fluid,  is  carried  over  all  the  districts 
■which  it  is  desired  to  cleanse.  The  wound  is  pinched  round  the  tube 
until  some  pints  have  flowed  into  the  abdomen,  and  it  has  begun  to  be 
distended';  the  wound  is  then  made  to  gape,  and  the  fluid  comes  out  with 
a  gush  carrying  debris  with  it.  This  may  be  done  repeatedly  till  the 
fluid  returns  quite  clear.  A  little  judicious  manipulation,  accompanied 
with  kneading  of  the  parietes,  and  perhaps  turning  of  the  patient  on  one 
side,  will  cause  most  of  the  fluid  to  escape.  If  drainage  is  to  be  carried 
out  it  is  not  necessary  to  remove  the  fluid,  in  fact  it  is,  I  think,  betrt;er  to 
leave  it  behind,  for  clotting  of  blood  does  not  then  take  place ;  if  there 
is  to  be  no  drainage  the  fluid  must  be  removed  by  sponging  in  the  manner 
directed. 

If  irrigation  is  employed  there  should  be  no  stinting  of  fluid  — 
gallons  rather  than  pints  should  be  the  measure.  The  bowels  should  be 
freely  moved  about  with  the  fingers  in  the  cavity  during  the  irrigation, 
so  as  to  ensure  disturbance  of  every  lurking  particle  of  foreign  matter. 

It  is  possible  to  overdo  the  peritoneal  cleansing.  Too  much  spong- 
ing irritates  the  peritoneum  and  causes  it  to  secrete  fluid,  and  removal 
of  every  particle  of  clot  encourages  vessels  to  go  on  bleeding.  Sponging 
may  cease  when  no  more  than  a  drachm  of  fluid  can  be  squeezed  from 
the  sjjonge.  If  the  drainage  tube  is  to  be  employed,  as  will  usually  be 
the  case  after  irrigation,  sponging  is  not  called  for  at  all. 

Drainage.  — It  is  quite  impossible  to  lay  down  accurate  rules  as  to  the 
employment  of  the  drainage  tube  in  ovariotomy.  It  is  certainly  true 
that  drainage  has  done  more  good  than  harm ;  Avith  moderate  care  it  can 
scarcely  do  harm :  therefore  it  is  a  good  rule  to  drain  when  in  doubt. 
If  fluids  do  not  come  away  the  tube  may  be  removed  in  twenty-four 
hours,  and  no  harm  is  done.  If  fluids  do  come  away  we  have  the  satis- 
faction of  seeing  the  good  done. 

If  we  expect  a  pouring  out  of  fluid,  serous  or  sanguinolent,  more 
rapid  than  the  peritoneum  can  dispose  of  we  should  drain.  This  would 
occur  after  extensive  traumatism  in  the  separation  of  adhesions.  If  we 
expect  bleeding  from  vessels  which  cannot  be  secured  we  should  drain, 
and  in  any  case  where  haemorrhage  is  feared  we  should  drain.  In  all 
cases  where  purulent  or  septic  fluid  has  escaped  into  the  cavity  we  should 
drain.  Where  intestine  or  bladder  or  other  viscixs  has  been  wounded, 
with  escape  of  their  contents,  we  should  drain.  And  in  most  cases  where 
irrigation  has  been  employed  it  is  wise  to  drain. 

Keith's  drainage  tubes  (Fig.  233)  are  for  most  cases  the  best.  The 
tube  selected  should  be  long  enough  to  reach  the  bottom  of  the  pouch  of 
Douglas  without  pressing  on  the  rectum,  while  the  collar  rests  on  the 
skin  at  the  lower  end  of  the  wound.  Inside  the  tube  should  be  placed 
a  few  strands  of  gauze  or  thread  to  act  as  capillary  drains.  A  circular 
sheet  of  rubber,  in  the  centre  of  which  a  hole  has  been  cut  to  admit  the 
end  of  the  tube,  is  folded  over  an  absorljciit  dressing  (nothing  is  better 
for  this  purpose  than  a  sponge-cloth  wrung  out  of  warm  carbolic  lotion) 
which  is  removed  as  often  as  it  is  saturated.     If   there  be  bleeding, 


OVARIOTOMY  893 


frequent  use  of  a  suction  apparatus  to  keep  the  abdomen  perfectly  dry 
is  advisable.  Tait's  suction  apparatus,  or  an  ordinary  glass  syringe 
with  a  piece  of  rubber  tubing  long  enough  to  reach  to  the  bottom  of 
the  glass  tube,  should  be  employed  for  this  purpose.  If  there  is  no 
clotting  the  capillary  drain  will  serve  to  keep  the  abdomen  dry  without 
the  use  of  the  suction  apparatus. 

The  gauze  drain  is  very  rarely  employed  after  ovariotomy. 

In  most  cases  drainage  need  not  be  continued  longer  than  two  or 
three  days ;  a  few  cases  require  drainage  for  a  week  or  even  longer. 
If  the  wound  is  thoroughly  aseptic  the  opening  made  by  the  tube 
closes  at  once  without  suppuration. 

Before  placing  the  drainage  tube  it  is  a  good  plan  to  insert  a  silk- 
worm gut  suture  through  the  parietes  at  the  point  where  the  tube 
passes,  and  leave  this  to  be  tied  after  the  tube  is  removed. 

Suturing  the  Parietal  Wound.  —  Some  surgeons  suture  the  wound  in 
layers,  each  tissue  having  its  row  of  buried  sutures,  interrupted  or  con- 
tinuous. Most  are  contented  with  interrupted  sutures,  of  which  each 
includes  all  the  layers  in  the  parietes.  Each  suture  should  include  skin 
and  subcutaneous  tissue,  take  a  good  hold  of  the  librous  aponeurosis, 
dip  deeply  into  muscle,  and  pick  up  subperitoneal  areolar  tissue  suffi- 
cient to  give  close  peritoneal  apposition  on  the  raw  surface.  It  should 
not  pierce  peritoneum.  The  sutures  should  be  placed  from  two  to  four 
to  the  inch ;  thin  and  lean  parietes  require  more  sutures  than  thick  and 
firm  parietes. 

As  suture  material  silk-worm  gut  is  unrivalled.  For  insertion  of  the 
sutures  a  curved  needle  on  the  Hagedorn  plan  is  recommended.  An 
ordinary  Hagedorn  needle  does  very  well.  With  the  needle  which  I 
employ  (Fig.  236)  the  sutures  can  be  placed  with  accuracy  and  rapidity. 

Before  suturing  is  begun,  a  sponge  of  suitable  size  is  placed  in  the 
cavity  under  the  parietes  to  keep  bowels  out  of  the  way,  and  to  collect 
any  blood  that  nuiy  escape  from  the  needle  punctures.  When  all  the 
sutures  are  placed  the  assistant  grasps  their  ends  in  his  two  hands ; 
the  sponge  is  then  removed  and,  from  above  downwards,  the  sutures 
are  tied.  If  drainage  is  used,  an  extra  suture  may  be  placed  where  the 
tube  passes,  but  is  not  tied ;  it  is  tied  when  the  tube  is  removed. 

A  Avound  which  is  properly  sutured  should  not  be  depressed,  but 
should  rather  pout  or  bulge  outwards.  By  burying  the  sutures  deeply  in 
the  parietal  muscle  and  fibrous  tissues  the  uniting  surfaces  are  broadened, 
and  tlie  adhesions  are  thereby  increased  in  resisting  power ;  superficial 
insertion  of  sutures  contracts  the  uniting  surfaces,  and  diminishes  the  bulk 
and  strength  of  the  adhesions.  The  aim  should  be  to  get  union  by  a  sort 
of  flange-stitch  which  opens  up  and  broadens  the  surfaces  to  be  united. 

Dressings.  —  Any  dressing  that  is  aseptic  and  absorbent  will  do.  As  a 
routine  dressing  I  sprinkle  a  little  l)orie  powder  around  the  wound,  and  then 
rub  it  into  the  skin  with  the  fingers  holding  a  few  drops  of  carbolic  lotion. 
Thus  any  germs  that  may  be  lurking  in  the  hair-follicles,  or  amongst 
the  epidermic  scales,  are  rendered  inert  if  not  destroyed.     Then  a  strip 


894  SYSTEM   OF  GYNAECOLOGY 

of  boric  lint  of  four  thicknesses  is  laid  over  the  wound,  and  the  whole 
is  covered  with  long  strips  of  strapping.  Primary  healing  is  practically 
universal ;  "  stitch  abscesses "  are  almost  unknown.  At  the  end  of  a 
week  the  wound  is  healed ;  but  the  stitches,  if  of  silk-worm  gut,  may 
with  propriety  be  left  in  for  three  weeks  until  the  young  cicatricial  tissue 
has  gained  density  and  strength.  I  believe  that  buried  sutures  are  of 
value  chiefly  because  we  cannot  remove  them;  they  keep  up  perfect 
apposition  for  about  three  weeks  till  they  are  absorbed.  By  leaving  in 
ordinary  sutures  for  three  weeks  Ave  get  this  advantage. 

Many  varieties  of  dressing  have  been  described.  One  of  the  best  is 
that  of  Howard  Kelly,  which  hermetically  seals  the  wound  and  prevents 
the  invasion  of  micro-organisms  from  without.  He  thus  describes  it  (1) :  — 

"  After  closure  of  the  incision,  the  skin,  the  line  of  the  wound,  and 
the  sutures  are  dried,  and  two  layers  of  sterilised  gauze  or  cheese-cloth, 
large  enough  to  project  from  two  to  four  inches  beyond  the  incision  on 
all  sides,  laid  on  the  skin.  This  is  saturated  with  the  following  adhesive 
mixture,  which  is  evenly  distributed  over  the  whole  surface :  Squibb's 
ether  or  washed  ether  and  absolute  alcohol,  equal  parts ;  bichloride  of 
mercury,  enough  to  make  the  solution  ys^-oo  5  snoAvy  cotton  (Anthony's), 
enough  to  make  a  syrupy  consistence,  added  in  small  pieces,  stirring.  As 
soon  as  this  is  poured  over  the  wound  evaporation  takes  place,  and  the 
celluloidin  hardens,  gumming  the  gauze  fast  to  the  skin.  To  avoid  delay 
in  waiting  for  this  to  grow  quite  hard,  and  to  prevent  adhesion  to  the 
cotton  applied  above  it,  the  whole  surface  is  freely  dusted  over  with  a 
finely  powdered  mixture  of  iodoform  (one  part)  and  boric  acid  (seven 
parts).  The  wound  thus  sealed  with  celluloidin  may  be  left  untouched 
for  a  week  or  more,  when  the  dressing  should  be  softened  with  water  (or 
more  rapidly  with  ether),  the  gauze  lifted  off,  and  the  stitches  taken  out." 


Variations  in  Method  of  Operating  according  to  the  Nature  and  Position 

of  the  Tumour 

la  Dermoid  Growths. — The  contents  of  dermoid  tumours  may  be 
cheesy  and  thick,  and  refuse  to  run  through  the  trocar.  In  such  cases  the 
best  x^ractice,  if  the  growth  be  not  very  large,  is  to  prolong  tlie  incision 
and  deliver  the  tumour  bodily.  If  the  tumoiir  is  large,  the  whole  space 
surrounding  the  tumour  is  packed  with  flat  sponges  ;  tlie  two  sides  of  the 
puncture  in  the  cyst  are  caught  by  large  catch-forceps  and  pulled  f(n-wards 
on  the  sponges,  and  the  contents  are  then  scjueezed  out  by  pressure  on 
the  parietes,  assisted  possibly  by  the  fingers  or  hand  inserted  into  the 
tumour  cavity.  The  most  scrupulous  care  should  be  taken  to  prevent 
escape  of  any  of  tlie  sebaceous  contents  into  the  abdominal  cavity.  The 
greasy  material  once  in  the  cavity  is  difficult  to  remove,  and  a  small 
quantity  left  inside  may  be  the  source  of  peritonitis.  Pure  dermoid  cysts 
are  not  often  of  large  size;  these  cysts  are,  however,  often  of  a  mixed 
kind,  and  then  may  reach  large  dimcnsicjns.    dermoids  would  seem  to  be 


OVARIOTOMY  895 

more  liable  to  rotation  of  the  pedicle,  even  to  the  extent  of  complete 
separation,  than  other  varieties  of  ovarian  growth. 

In  Solid  Tumours.  —  In  the  removal  of  solid  tumours  of  whatever 
nature  a  long  incision  is  necessary.  For  help  in  delivery,  the  insertion 
of  a  myoma-screw  (Fig.  241)  into  the 
substance  of  the  tumour  may  be  of  as- 
sistance. The  force  of  suction  is  over- 
come by  inserting  the  fingers  between 
the  tumour  and  the  deep  parts  so  as  to 
admit  air.  When  the  tumour  is  de- 
livered a  large  sponge  or  diaphragm  is 
placed  in  the  cavity  over  the  bowels  to 
prevent  their  extrusion.  The  pedicle 
in  these  cases  is  often  very  vascular  and 
fleshy;  it  does  not  often  include  the 
Fallopian  tube.  The  vessels  being  very 
thin  walled  are  liable  to  be  torn  by 
transfixion,  even  with  a  blunt  instru- 
ment;  therefore  unless  the  pedicle  be 

thick    and     fleshy,    a     single     encircling        Fig.  241. -screw  for  aiding  in  the  delivery 
•^ '  ^  ^  ^  of  scud  tumours.    \  size. 

ligature  is  admissible.    The  pedicle  is 

first  compressed  by  powerful  forceps  at  the  site  of  ligation.  While 
the  ligature  is  being  tightened  the  tumour  is  cut  off  by  scissors,  every 
cut  by  the  scissors  permitting  the  ligature  to  be  drawn  more  tightly ; 
when  division  is  complete  the  absence  of  bleeding  from  the  divided 
surface  shows  that  suflicient  constriction  has  been  exerted,  and  the  knot 
is  tied.  If  the  pedicle  be  thick,  a  chain  interlocking  ligature,  placed  as 
already  described,  must  be  employed. 

The  rare  papillomatous  tumours  of  the  ovary  are  removed  in  the  same 
way  as  solid  tmnours.  As  they  bleed  freejy  on  being  handled,  and  as 
fragments  of  the  papillary  tufts  are  liable  to  be  broken  off  and  may 
infect  the  peritoneum,  it  is  well  to  surround  the  tumour  by  a  sponge- 
cloth  before  it  is  handled ;  and  to  carry  out  all  manipulations  while  the 
tumour  is  wrapped  up  in  the  cloth. 

In  Tumours  groiving  between  the  Layers  of  the  Broad  Ligament.  —  Cer- 
tain tumours  having  origin  in  the  ovary,  the  paroophoron  and  the  parova- 
rium, are  liable  to  develop  between  the  laA'ers  of  the  broad  ligament. 
An  ordinary  cystoma  may  do  this;  it  is  then  known  as  "encapsuled." 
Tumours  originating  in  the  parovarium — simple  parovarian  cysts  —  may 
be  encapsuled.  Papillomatous  cysts,  which  undoubtedly  frequently  origi- 
nate in  the  paroophoron  or  hilum  of  the  ovary,  are  very  frequently  encap- 
suled ;  that  is,  they  grow  between  the  layers  of  the  broad  ligament,  and 
open  them  up.  Some  cases  have  half  the  cyst  outside  and  half  inside  the 
peritoneal  covering ;  some  are  completely  enveloped.  Papilloraa-bearing 
cysts  may  present  man}''  ditficiilties  in  removal. 

A  tumour,  opening  up  the  broad  ligaments  and  covered  by  peritoneum 
and  its  underlying  areolar  tissue,  has  a  pink  opaque  surface,  very  different 


896  SYSTEM  OF  GYNMCOLOGY 

from  the  ■s^'hite  or  gray  glistening  surface  of  the  wall  of  a  cystoma.  It 
is  tapped  as  usual,  and,  as  far  as  possible,  delivered.  There  will  be  no 
proper  pedicle ;  the  whole  length  of  the  broad  ligament  may  be  involved, 
and  the  growth  may  dip  deeply  into  its  substance. 

In  the  enucleation  of  all  these  tumours  two  practices  may  wisely  be 
followed:  firstly,  to  begin  by  tying  off  as  much  tissue  as  possible  at  the 
uterine  cornu,  this  will  check  all  bleeding  coming  from  the  anastomosis 
between  the  uterine  and  ovarian  arteries,  which  is  the  chief  blood-supply  ; 
and,  secondly,  to  do  as  little  enucleation  as  possible,  but  instead  to  carry 
division  of  the  broad  ligaments  well  down  into  the  pelvis.  It  saves 
bleeding  to  cut  off  the  utero-ovarian  blood-supply  from  the  beginning. 
It  saves  time,  and  removes  superfluous  and  perhaps  dangerous  tissue,  to 
cut  away  with  the  tumour  large  flaps  of  the  spread-out  broad  ligaments. 
It  is  waste  of  time  to  separate  flaps  of  peritoneal  tissue  from  the  tumour- 
wall  when  both  are  to  be  removed. 

In  such  cases  a  ligature  is  placed,  by  transfixion  with  the  bent  pedicle 
forceps,  between  the  uterine  cornu  and  the  tumour;  then  the  areolar 
tissue  beyond  the  ligature  is  opened  up.  Guided  by  the  forefinger,  the 
peritoneum  is  divided  in  a  line  leading  as  nearly  as  possible  straight 
between  the  cornu  and  the  pelvic  attachment  of  the  broad  ligament. 
Catch-forceps  are  placed  on  the  bleeding  points  as  they  appear,  and  are 
left  attached  till  enucleation  is  complete,  when  they  may  be  replaced  by 
ligatures  if  necessary.  Usually,  however,  forcipressure  for  a  few  moments 
will  be  found  sufiicient  to  check  all  the  bleeding.  Wlien  a  beginning 
is  made,  enucleation  may  usually  be  carried  out  very  rapidly  by  the 
fingers,  an  adhesion  here  and  there  being  caught  in  forceps  and 
divided. 

The  raw  surfaces  left  after  enucleation  should  be  covered  in  by 
suturing  together  the  peritoneal  free  margins,  otherwise  bowels  will 
become  adherent  to  them,  apd  obstruction  may  ensue.  The  danger  of 
the  formation  of  a  haematoma  between  the  layers  of  the  ligaments  is 
avoided  by  seciiring  perfect  haemostasis,  and  perhaps  by  placing  a  small 
rubber  tube  in  the  cavity,  and  taking  it  out  at  the  bottom  of  the  parietal 
incision.     It  may  be  removed  in  twenty-four  hours. 

In  some  of  these  cases,  more  especially  of  the  papillomatous  variety, 
the  whole  of  one  side  of  the  uterus,  or  even  of  both  sides,  may  be  entirely 
denuded  of  ligaments.  In  such  a  condition  the  checking  of  bleeding 
from  the  uterine  vessels  may  require  many  ligatures,  or  even,  as  I  have 
found,  the  application  of  the  actual  cautery. 

Ovariotomy  during  pregnancy  requires  no  special  description  for 
tlie  early  stages.  In  the  later  stages  of  jn-egnancy,  if  the  tumour  be  well 
to  one  side  and  the  uterus  to  the  other,  a  lateral  incision  over  the  probable 
position  of  the  pedicle  will  cause  less  disturbance  of  parts  and  give  easier 
access  than  a  median  incision  which  necessitates  some  lateral  displacement 
or  even  rotation  of  the  uterus.  Special  care  is  given  to  the  ligation  of 
the  pedicle  which  may  contain  large  vessels.     The  operation  in  every  case 


OVARIOTOMY  897 


should  be  performed  with  as  little  disturbance  of  parts  as  possible,  so  as 
to  lessen  the  tendency  to  abortion. 

Incomplete  Operations.  —  The  number  of  incomplete  operations, 
instead  of  diminishing  as  we  might  expect,  seems  to  be  on  the  increase. 
We  should  expect  their  number  to  diminish  because  early  diagnosis  and 
early  operation  have  made  ovariotomy  an  easier  operation  than  it  was 
thirty  years  ago,  when  late  diagnosis  was  more  common,  and  delay  until 
the  patient  could  not  walk  was  the  rule.  One  experienced  surgeon 
records  no  less  than  twenty  per  cent  of  unfinished  operations,  another 
three  per  cent.  These  cases  are  sometimes  complacently  put  down  as 
"recovered," — more  truly  it  might  be  said  of  them,  '*  abandoned  to  death." 
In  England,  amongst  experienced  operators,  it  is  the  rarest  possible 
event  to  have  an  incomplete  ovariotomy.  In  a  personal  experience  of 
over  two  hundred  operations,  with  no  case  refused,  I  have  never  left  an 
operation  incompleted.  If,  as  most  experienced  surgeons  insist,  there 
is  no  cystic  growth  of  the  ovary  which  cannot  be  removed,  a  heavy  re- 
sponsibility rests  on  the  surgeon  who  fails  to  complete  the  work  he  has 
begun.  Deaths  are  certainly  most  numerous  after  the  most  desperate 
operations ;  these  operations  ruin  statistics,  but  they  save  lives.  In  the 
belief  that  the  interests  of  our  patients  and  of  surgery  are  best  served 
by  the  completion  of  an  ovariotomy  once  begun,  I  make  no  attempt  to 
formulate  rules  for  guidance  in  the  case  of  operations  left  unfinished ; 
nor  any  attempt  to  classify  unremovable  tumours,  because,  in  the  opin- 
ion of  those  most  competent  to  judge,  there  are  no  such  tumours. 

Accidents  —  Complications. — An  ordinary  ovariotomy  is  one  of  the 
most  straightforward  and  precise  of  operations,  in  which  nothing  but 
ignorance  or  want  of  experience  can  lead  to  error.  But  extraordinary 
cases  are  constantly  met  with  in  which  unusual  conditions  lead  to  par- 
donable accidents.     The  most  common  of  these  may  be  described. 

Extrusion  of  Bowels.  —  Through  straining  of  the  patient  or  sudden 
delivery  of  a  tumour,  intestinal  coils  may  escape  from  the  cavity  and 
roll  out  over  the  abdomen.  If  the  surgeon  is  engaged  in  other  important 
work,  it  is  the  assistant's  duty  to  prevent  this  by  timely  placing  of 
sponges,  or  by  the  insertion  of  Maunsell's  diaphragm.  During  delivery 
of  a  tumour  the  surgeon's  left  hand  will  instinctively  seek  to  prevent 
extrusion  of  bowels.  When  many  coils  have  escaped  they  are  at  once 
covered  by  a  sponge-cloth;  the  forefinger  of  the  assistant  is  hooked  in 
under  the  top  of  the  incision  to  pull  the  parietes  well  forward,  while 
the  surgeon,  with  both  hands  spread  over  the  sponge-cloth,  compresses 
and  empties  the  intestines,  and  then  slips  them  inside.  A  recurrence 
of  the  accident  is  prevented  by  the  insertion  of  a  suture  in  the  wound, 
or  by  i)lacing  sponges  or  the  artificial  diaphragm. 

Stripping  the  parietal  peritoneum  from  the  parietes  in  the  belief 
that  an  adherent  cyst-wall  is  being  separated,  is  an  accident  that  may 
happen  to  inexperienced  operators.     If  the  patient  is  thin  there  may 

3m 


SYSTEM  OF  GYNECOLOGY 


be  but  little  subperitoneal  fat,  and  the  peritoneum  may  be  so  loosely 
attached  that  it  readily  peels  off.  The  whole  anterior  parietes  may 
thus  be  denuded  by  reckless  manipulation.  If  the  peritoneum  be  very 
thin  and  has  been  roughly  handled,  it  had  better  be  removed  than  left 
to  the  risk  of  gangrene.  Occasionally  separation  of  a  very  thick  peri- 
toneum adherent  to  a  suppurating  or  gangrenous  cyst  is  accidentally 
made.  It  is  better  to  do  this  than  to  tear  the  cyst-wall,  which  may  be 
on  the  point  of  rupturing  at  the  seat  of  adhesion.  Such  pieces  of  sepa- 
rated peritoneum  should  be  removed  with  the  tumour. 

Rupture  of  the  cyst-ivall  in  any  way,  but  especially  by  pushing  a  trocar 
right  through  both  sides  of  it,  need  not  do  much  harm  unless  the  contents 
of  the  cyst  be  putrid.  Frequently  the  walls  of  the  cyst  are  so  friable 
that  they  will  not  hold  together  under  the  forceps,  and  tear  even  under 
gentle  handling  by  fingers.  In  such  cases  it  is  impossible  to  prevent  the 
escape  of  some  of  the  cyst-contents,  and  this  should  be  provided  for  by 
packing  in  large  sponges  under  the  tumour.  We  may  have  to  operate 
for  rupture  of  a  cyst.  In  one  such  case  I  discovered  almost  accidentally, 
high  up  in  the  abdomen,  a  mass  of  gangrenous  glandular  tissue  as  large 
as  the  fist,  which  had  escaped  at  the  time  of  rupture  and  was  embedded 
in  adhesions.  It  was  removed  in  the  belief  that  it  was  an  unreckoned 
sponge.  Solid  glandular  masses  may  similarly  escape  during  operation 
in  cases  of  rotten  cysts.  Such  rents  may  sometimes  be  closed  by  forceps. 
Complete  delivery  of  the  tumour  is,  however,  the  end  to  be  aimed  at; 
while  during  the  manipulation  it  must  be  as  completely  isolated  by 
sponge-packing  as  adhesions  will  permit.  Irrigation  will  be  called  for 
in  these  cases. 

Hcemorrhage  to  an  alarming  extent  may  be  caused  by  injury  to  the 
walls  of  a  very  vascular  tumour,  or  of  one  of  the  large  pelvic  or  mesen- 
teric vessels,  or  by  division  of  vessels  in  adhesions.  If  bleeding  from 
the  cyst-wall  is  very  free,  and  the  tumour,  on  account  of  adhesions, 
cannot  at  once  be  delivered,  a  large  pressure-forceps,  placed  temporarily 
on  the  pedicle,  will  check  the  bleeding  for  the  time.  I  have  met  with 
a  general  varicose  condition  of  the  omentum  and  anterior  parietes  in  a 
case  of  solid  ovarian  tumour,  in  which  very  free  bleeding  took  place  on 
handling.  The  occurrence  of  bleeding  from  injury  to  any  of  the  iliac 
veins  is  a  very  serious  accident,  and  difficult  to  deal  with.  A  wound  in 
a  large  vein  may  be  sutured ;  a  small  vein  should  be  tied  on  both  sides 
of  the  wound  or  tear.  General  oozing  from  a  large  denuded  surface 
may  be  controlled  by  firm  pressure  with  sponges  or  gauze.  Occasionally 
styptics,  or  the  actual  cautery,  will  be  required.  Haemorrhage,  after 
oiK;ration,  is  usually  from  an  iinjiei-fectly  secured  pedicle  :  this,  if  in  any 
quantity,  requires  reopening  of  the  abdomen  and  satisfactory  ligation. 
Effused  clot  will  Vje  removed  and  the  cavity  cleansed  by  sponging  or 
irrigation.  A  drainage  tube,  inserted  for  a  few  hours,  will  add  to  the 
security. 

Inju/nes  to  the  hollow  viscera  may  occur  under  the  most  skilful 
management,  and  are  sometimes  unavoidable.     In  every  case  they  are 


OVARIOTOMY 


serious,  and  should  be  dealt  with  at  the  earliest  possible  moment. 
Intestine  is  usually  lacerated  during  the  separation  of  old  dense  adhe- 
sions, Avheii  the  bowel  is  embedded  in  a  deep  sulcus  between  two  cysts. 
It  should  be  sutured  at  once  by  Lembert's  or  Dupuytren's  method. 
The  vermiform  appendix  is  sometimes  embedded  in  a  sulcus,  and  firmly 
adherent ;  it  is  best  to  amputate  it  at  once,  and  not  to  attempt  to  sepa- 
rate it  from  the  tumour. 

Injury  to  the  walls  of  the  bladder  are  more  common  than  complete 
laceration.  The  latter  condition,  of  course,  demands  accurate  suturing. 
If  the  injury,  while  not  penetrating  the  mucous  membrane,  involves  the 
muscular  coat  to  any  extent,  it  is  wise  to  place  some  puckering  sutures 
for  safety.  Kupture  of  the  gall-bladder  is  a  rare  injury  during  ovari- 
otomy ;  the  rent  should  be  closed  at  once,  and  special  gauze  drainage 
provided  through  a  separate  opening. 

The  ureter  is  liable  to  accident,  either  by  inclusion  in  the  pedicle- 
ligature  or  by  division.  If  the  ureter  be  divided,  and  the  accident 
discovered  at  the  time,  it  is  best  to  unite  it  at  once  by  the  operation 
known  as  uretero-ureterostomy.  If  the  injury  be  discovered  later  in 
the  progress  of  the  case,  either  operation,  or  the  implantation  of  the 
ureter  into  the  bladder,  may  be  carried  out.  The  full  management  of 
the  case  in  such  a  condition  cannot  here  be  detailed. 

Injuries  to  the  solid  viscera  —  liver,  kidney,  or  spleen  —  are  not 
usually  of  serious  moment.  They  are  mainly  of  the  nature  of  peri- 
toneal denudations  done  during  the  separation  of  adhesions,  and  are 
dangerous  only  Avhen  there  is  excessive  bleeding.  The  use  of  the  actual 
cautery,  or  a  solution  of  perchloride  of  iron,  will  usually  be  effectual  in 
checking  the  bleeding ;  if  these  fail,  gauze  packing  may  be  employed. 

Foreign  bodies  left  in  the  cavity  —  sponges,  forceps,  or  other  instru- 
ments —  have  caused  a  good  many  deaths  after  ovariotom}'.  Preven- 
tion is  the  best  remedy  here ;  instruments  and  sponges,  before  and  after 
operation,  should  always  be  accurately  counted.  As  soon  as  it  is  cer- 
tain, or  even  probable,  that  a  foreign  body  has  been  left  inside,  the 
abdomen  should  be  reopened  and  the  body  sought  for  and  removed. 

Intestinal  obstruction,  following  ovariotomy  or  oophorectomy,  arises 
in  most  cases  from  adhesion  of  bowel  to  the  stump  of  the  divided 
pedicle.  The  false  obstruction,  arising  from  the  intestinal  paresis 
which  accompanies  peritonitis,  is  considered  under  treatment  after 
operation,  and  need  not  here  be  dwelt  upon. 

About  two  per  cent  of  all  the  deaths  after  ovariotomy  are  caused  by 
obstruction,  induced  by  kinking  of  a  loop  of  bowel  which  has  become 
adherent  to  the  raw  end  of  the  divided  pedicle.  This  accident  is  most 
liable  to  occur  after  removal  of  the  appendages  for  myoma.  Here  the 
restricted  space  between  tumour  and  parietes,  in  which  bowel  is  caught 
and  compressed,  both  disposes  to  the  accident  and  aggravates  the  result 
of  it.  Traction  of  the  adherent  gut  produces  kinking,  and  this  is,  in 
most  cases,  the  final  cause  of  the  obstruction. 

Obstruction  may  be  caused  by  the  bowel  getting  caught  in   the 


900  SYSTEM  OF  GYNECOLOGY 

pedicle-ligatiire,  or  in  a  parietal  suture.  Holes  left  in  omentum,  mesen- 
tery, or  broad  ligament,  may  cause  obstruction  if  the  bowel  slip  through 
them  and  get  entangled. 

The  symptoms  of  obstruction  vary  with  the  cause.  In  ordinary 
cases,  caused  by  adhesion  of  bowel  to  pedicle,  the  symptoms  come  on 
at  some  period  between  the  third  and  fifth  day,  and  are  of  the  ordinary 
character  met  with  in  non-operative  cases.  Vomiting,  abdominal  dis- 
tension, insuperable  constipation,  and  more  or  less  collapse,  may  be 
expected.  Where  bowel  is  caught  in  a  ligature  the  symptoms  come  on 
at  once,  and  quickly  become  serious.  It  requires  some  experience  and 
keenness  of  insight  to  diagnose  intestinal  obstruction  with  certainty 
after  ovariotomy. 

As  soon  as  the  condition  is  diagnosed  the  abdomen  should  be  re- 
opened and  the  gut  liberated.  Entrance  may  be  made  through  the 
healing  incision,  by  separating  the  adherent  margins  of  the  wound  by 
finger  or  blunt  dissector.  If  the  cause  is  at  the  seat  of  the  parietal 
incision  it  is  removed  almost  on  discovery.  If  at  the  pedicle,  the  bowel 
and  pedicle  are  brought  to  the  surface  and  separation  is  made  under 
view.  The  adhesion  in  such  cases  may  be  very  close  and  intimate ;  and, 
if  intestinal  wall  is  likely  to  suffer  much  injury  in  the  separation,  it  is 
better  to  shave  off  a  piece  of  the  stump  and  leave  it  attached  to  the  bowel, 
than  to  incur  any  risk  of  rupturing  the  intestine  by  separation.  Any  lac- 
eration of  gut  should  be  closed  at  once  by  a  Lembert  or  Dnpuytren  suture. 

After  Treatment. — Nothing  in  the  whole  range  of  surgery  is  more 
remarkable  than  the  ease  and  rapidity  with  which  a  patient  recovers 
after  an  ordinary  ovariotomy.  If  we  let  the  patient  alone,  and  do  not 
worry  her  with  fussy  regulations  and  injudicious  applications  of  tenta- 
tive therapeutics,  she  will  probably  feel  perfectly  well  on  the  third  or 
fourth  day.  She  may  lie  in  any  position  she  likes,  on  back  or  side ; 
she  may  pass  water  when  she  desires,  and  need  not  do  so  before ;  and 
within  wide  limits  she  may  drink  what  she  likes,  provided  it  is  not 
cold  and  is  absorbed  by  the  stomach.  To  keep  the  patient  in  the  supine 
posture,  to  draw  the  water  at  stated  intervals,  and  to  starve  the  patient 
of  all  liquids  are  quite  unnecessary  in  the  majority  of  cases,  and  cause 
suffering  in  not  a  few.  Comfort  is  a  therapeutic  measure  of  real  im- 
portance, and  we  should  do  everything  possible  to  promote  it.  We 
should  look  with  suspicion  on  any  adjuvant  to  surgical  healing  which 
causes  discomfort  or  suffering  to  the  patient. 

One  of  the  most  common  complaints  after  ovariotomy  is  backache. 
The  causes  of  it  are  various :  the  strain  of  keeping  straight  on  a  hard 
mattress  a  back  which  is  naturally  curved  is  probably  one  cause ;  it  is 
certain  that  to  turn  the  patient  first  on  one  side  and  then  on  the  other 
affords  most  relief.  A  hot  rubber-cushion  or  water-bottle  under  the 
sacrum  often  removes  the  acliing.  Changing  the  patient  from  one  bed 
to  another,  with  clean  fresh  linen  and  well-shaken  mattress,  is  a  luxury 
which  is  always  highly  ay)pre('.iato(l. 


OVARIOTOMY  901 


Thirst  in  this,  as  in  most  other  abdominal  operations,  is  nearly  always 
present.  Some  surgeons  withhold  all  liquids  by  the  mouth  for  the  first 
twenty-four  or  forty-eight  hours ;  this  aggravates  the  thirst,  sometimes 
almost  to  torture.  If  there  be  special  reasons  for  withholding  liquids 
by  the  mouth,  a  pint  of  hot  water,  administered  slowly  by  the  rectum, 
will  relieve  the  thirst;  and  a  second  administration,  after  six  hours,  will 
probably  remove  it.  But  in  ordinary  cases  liquids  may  be  given  by  the 
mouth  almost  from  the  beginning.  Most  women  prefer  hot  tea  made  to 
their  own  taste,  and  with  it  a  little  dry  toast  may  be  given.  Gruel, 
one  of  the  ordinary  children's  foods  such  as  Benger's  or  ■Mellin's, 
barley  water  or  toast  water,  or  almost  anything  the  patient  likes,  except 
milk,  may  be  given  by  the  mouth.  On  the  second  day  home-made  beef 
tea,  or  any  of  the  concentrated  beef  essences,  may  be  given,  well  diluted. 
Often  on  the  third,  nearly  always  on  the  fourth  day,  the  patient  may  be 
permitted  to  order  her  own  diet.  After  the  fourth  day  solid  or  con- 
centrated foods  are  preferable  to  liquid  and  very  dilute  foods ;  they 
produce  less  flatulence,  and  are  usually  liked  better.  Fish,  chicken, 
game,  boiled  or  stewed,  and  not  roasted,  may  be  given  on  the  fourth 
day ;  and  thereafter  the  diet  scarcely  requires  regulation.  Fruit  of  all 
sorts  may  be  given  throughout.  Milk  is  not  a  good  food  after  abdomi- 
nal operations;  it  causes  flatulence  and  promotes  constipation,  or  rather 
permits  it. 

The  functions  of  the  bladder  require  special  attention.  It  used  to 
be  the  custom  to  draw  the  urine  off  by  catheter  at  regular  and  stated 
intervals  after  operation,  Avhether  the  patient  desired  it  or  not.  This  is 
not  necessary.  As  a  rule  the  catheter  need  not  be  passed  till  the  patient 
desires  to  micturate,  and  then,  if  she  can,  she  may  be  permitted  to  do  so. 
It  is  rarely  necessary  to  interfere  during  the  first  twenty -four  hours. 
The  amount  of  urine  secreted  is  diminished  considerably  after  ovari- 
otomy, and  remains  under  the  normal  for  about  a  week.  On  the  first 
day  about  15  ounces,  on  the  second  20,  on  the  third  26  may  be  expected. 
Therefore,  if  the  patient  cannot  herself  micturate,  one  passing  of  the 
catheter  on  the  first  day,  two  on  the  second,  and  three  on  the  third  and 
subsequent  days,  should  suffice;  unless  there  be  a  desire  for  relief  on  the 
part  of  the  patient.  To  avoid  catheter-cystitis  strict  attention  should  be 
given  to  the  purification  of  the  orifice  of  the  urethra  and  of  the  catheter. 
A  metal  catheter,  which  can  be  sterilised  by  boiling  or  heat,  is  safer 
than  a  catheter  of  soft  material  which  cannot  be  so  treated.  Catheter- 
cystitis,  which  is  simply  septic  cystitis,  may  be  very  troublesome,  lasting 
over  weeks ;  therefore,  strict  personal  attention  should  be  given  to  this 
item  in  the  treatment. 

At  the  end  of  the  second  or  third  day  the  bowels  should  be  evacuated. 
Ordinarily  this  is  best  secured  by  a  soap  and  turpentine  enema. 
Usually  great  quantities  of  gas  come  away  with  the  enema,  and  the 
abdomen  becomes  flat  or  concave.  A  seidlitz  powder,  given  the  first 
thing  in  the  morning  of  the  third  day,  if  the  patient  can  take  it,  will 
have  an  equally  good,  or  even  a  better  effect,  if  it  acts ;  but  it  is  some- 


SYSTEM   OF  GYNECOLOGY 


what  uncertain.  On  the  third  or  fourth  day  an  active  purge  of  colocynth 
may  be  administered.  Thereafter  the  bowels  are  kept  acting  by  any 
means  the  surgeon  considers  suitable. 

These  remarks  refer  to  the  ordinary  progress  of  an  uncomplicated 
case.  A  serious  operation  is  followed  by  a  serious  illness  of  the  kind 
which  follows  all  grave  operations,  and  it  is  treated  on  the  same  prin- 
ciples. Such  an  illness,  classed  under  the  broad  term  "  shock,"  is  soon 
over.  Specially  dogging  the  graver  operations,  but  also  sometimes  fol- 
lowing ordinary  ones,  is  a  complication  of  troubles  which  are  often 
classed  vaguely  as  peritonitis,  and  which  present  themselves  as  abdomi- 
nal distension,  obstruction  of  intestines,  and  vomiting. 

Severe  shock  or  collapse  after  operation  is  combated  by  the  appli- 
cation of  heat  to  the  body  surface ;  by  elevation  and  bandaging  of  the 
limbs;  by  hypodermic  injections  of  ether;  and  by  rectal  injections 
containing  brandy.  Irrigation  of  the  cavity  with  water  heated  to  105° 
or  110°  F.  has  been  spoken  highly  of  as  treatment  of  shock.  Near  the 
end  of  a  bad  operation  it  is  good  practice  to  administer  a  four-ounce 
rectal  injection,  containing  an  ounce  of  brandy;  and  to  repeat  this  every 
four  hours  till  the  patient  is  out  of  danger.  Hypodermic  injections  of 
strychnine  are  spoken  highly  of  by  some  surgeons,  not  only  as  helping  to 
prevent  shock,  but  also  as  causing  contraction  of  the  intestines.  Mor- 
phine is  not  to  be  administered  except  in  cases  of  great  restlessness  or 
jactitation;  then  it  is  of  real  value.  The  objections  to  it  are  the  gaseous 
distension  of  the  intestines,  and,  in  some  patients,  the  nausea  and  vomit- 
ing which  it  produces.  After  every  serious  operation  it  is  wise  to  begin 
rectal  feeding  at  once,  and  this  should  be  continued  until  the  patient, 
without  losing  ground,  can  get  on  with  nourishment  taken  by  the 
mouth. 

The  condition  which  is  most  dreaded  after  ovariotomy  has  been 
vaguely,  perhaps  inaccurately,  but  conveniently  described  as  originating 
in  peritonitis.  The  exact  pathology  of  the  condition  is  not  ascertained; 
probably  it  has  several  causes,  not  one  of  which  may  be  peritonitis.  It 
manifests  itself  by  three  almost  uniform  signs  —  vomiting,  abdominal 
distension,  and  constipation.  Whatever  be  the  prime  cause,  our  only 
means  of  curing  the  disease  is  by  fighting  the  symptoms. 

Extensive  and  serious  injury  to  the  peritoneum  is  probably  followed 
by  peritonitis.  A  traumatic  peritonitis,  with  abundant  exudates,  pro- 
vides a  convenient  medium  for  .septic  invasion.  Thus,  though  it  practi- 
cally happens  that  septic  peritonitis  is  chiefly  associated  with  traumatic 
peritonitis,  they  are  not  necessarily  connected;  the  one  may  exist  with- 
out the  other.  If  the  patient  gets  well  we  cannot  say  whether  it  has 
been  septic  or  traumatic;  it  may  have  been  both.  After  death  the  diffi- 
culty is  little  less ;  post-mortem  peritoneal  fluids  are  culture  media  for 
all  contiguous  intestinal  germs,  and  their  presence  in  peritoneal  exudates 
after  death  is  no  certain  pi'oof  of  their  presence  during  lif(;. 

As  yet  we  can  only  treat  the  disease  l)y  meeting  its  manifestations. 

The  first  .symptom  we  have  to  deal  with  is  vomiting.     Arising  after 


OVARIOTOMY 


903 


recovery  from  the  anaesthetic,  and  continuing  over  the  first  day  or  two, 
it  may  be  nothing  more  than  anaesthetic  sickness ;  continuing  over  the 
third  or  fourth  day,  or  beginning  on  the  third  and  continuing,  it  means 
something  more,  and  is  of  grave  moment.  It  is  useless  to  seek  to  con- 
trol it,  nor  is  it  wise  to  attempt  to  do  so.  Vomiting  relieves  over-di.s- 
tended  intestines,  and  should  be  encouraged  rather  than  repressed.  The 
stomach  should  not  be  worried  with  food ;  this  simply  adds  to  the  labour 
of  rejection :  none  of  it  is  absorbed. 

As  soon  as  vomiting  has  set  in  the  patient  should  be  fed  entirely  on 
stimulating  enemas.  A  good  routine  enema  is  an  ounce  of  brandy,  two 
drachms  of  concentrated  beef  jelly,  and  milk,  peptouised  or  not,  up  to 
four  ounces.  Not  much  milk  is  absorbed,  but  it  acts  as  a  diluent,  and  is 
well  tolerated  by  the  rectum.  Once  in  the  day,  at  least,  a  large  turpen- 
tine enema  should  be  given ;  it  will  bring  away  quantities  of  gas  and  un- 
absorbed  and  putrefying  residues  of  food,  and  will  cleanse  the  large 
bowel :  the  turpentine  has  probably  some  antiseptic  influence  as  well. 
Constant  vomiting  of  small  quantities  is  very  exhausting  to  the  patient, 
and  is  often  associated  with  over-distension  of  the  stomach ;  in  such  a  case 
it  is  often  good  treatment  to  pass  the  stomach-tube  and  empty  the  stomach. 
If  the  stomach  be  not  over-distended,  but  vomiting  frequent,  it  may  do 
good  to  give  a  large  drink  of  soda-water,  so  as  to  encourage  one  attack 
of  free  vomiting.     A  period  of  rest  often  follows  such  treatment. 

Usually  associated  with  the  vomiting  is  tympanitic  distension  of  the 
intestines.  The  condition  is  well  named  "  Pseudo-ileus."  It  is  a  form  of 
intestinal  obstruction  without  a  mechanical,  or  at  any  rate  a  constricting 
cause.  The  influences  at  work  in  the  production  of  pseudo-ileus  are 
probably  varied ;  certainly  one  of  them  is  a  condition  of  intestinal  paresis 
whereby  stasis  of  intestinal  contents  is  produced.  If  we  can  overcome 
this  condition,  if  we  can  make  the  intestines  act,  we  shall  probably  cure 
the  patient.  This  has  been  written  and  spoken  of  as  the  treatment  of 
peritonitis  by  purgatives,  and  many  arguments  have  been  used  for  and 
against  the  treatment.  It  is  probably  not  so  much  the  peritonitis  as  the 
paretic  ileus  which  is  attacked  and  cured  by  purgation.  When  the  latter 
is  removed  the  former  cures  itself.  It  is  certain  that  a  sharp  purge  will 
often  put  a  completely  new  aspect  on  a  case  which  is  drifting  hopelessly 
on  to  death  with  tympanitic  distension  and  vomiting.  Enormous 
quantities  of  gas  and  fluid  fjfices  are  passed ;  the  abdomen,  before  dis- 
tended and  brawny,  becomes  flat  and  soft;  vomiting  ceases;  and  the 
patient  expresses  a  sense  of  relief  which  usually  culminates  in  refreshing 
sleep.  There  is  probabl}'  no  single  effect  of  a  drug  in  the  whole  of 
surgical  practice  more  strikingly  beneficent  than  this  one  of  a  purge  in 
operation-ileus.  For  mild  cases  a  seidlitz  powder  will  usually  suffice. 
For  more  severe  cases  a  full  dose  of  colocynth  and  jalap,  or  a  calomel 
powder  may  be  given.  The  treatment  of  the  full  consequences  may  well 
be  carried  into  the  beginnings  of  the  trouble.  In  other  words,  we  may 
wisely  keep  the  bowels  acting  almost  from  the  beginning.  If  the  routine 
turpentine  enema  fail  to  keep  the  abdomen  flat  a  purgative  should  at 


904  SYSTEM   OF  GYNECOLOGY 

once  be  given  by  the  mouth ;  and  this  should  be  repeated  once  or  twice 
while  there  is  any  marked  tendency  to  distension. 

An  invaluable  adjuvant  in  the  treatment  of  flatulent  distension  is 
the  passing  and  wearing  of  the  rectum  tube.  The  vaginal  tube  which 
accompanies  a  Higginson's  syringe  does  very  well  for  the  purpose,  and 
is  a  good  model  as  regards  size  and  length  for  any  specially  made  tube. 
It  is  best  used  with  the  patient  on  her  side,  and  the  hips  raised  so  that 
the  gases  rise  to  it.  The  intestines  contract  at  intervals  ;  the  large 
bowel  may  be  emptied  in  the  iirst  few  seconds ;  then  after  a  minute  or 
two  more  gas  comes  into  it  from  the  small  intestines,  and  is  passed ; 
then  after  another  interval  more  gas  is  passed,  and  so  on  till  the  abdomen 
becomes  flat.  It  is  a  good  plan  to  let  the  patient  wear  the  rectum  tube 
for  half  an  hour  before  the  enema  is  due,  to  pass  the  enema  up  the  tube, 
and  then  to  remove  it.  A  skilled  nurse  will  be  able,  by  judicious  intro- 
duction of  the  rectum  tube,  to  render  most  important  assistance  in  the 
recovery  of  the  patient. 

The  pyrexia  which  follows  ovariotomy  scarcely  ever  requires  treat- 
ment. In  simple  cases  there  is  usually  a  rise  to  99*5°  or  100°  F.  on 
the  second  day,  and  this  usually  falls  to  normal  on  the  third  or  fourth 
day.  In  bad  cases  there  is  rarely  any  rise  at  all ;  in  the  worst  cases,  and 
especially  those  with  septic  peritonitis,  the  temperature  is  usually  sub- 
normal till  just  before  death,  when  it  rapidly  rises.  So  rare  is  a  danger- 
ous rise  of  temperature  that  no  provision  need  be  made  to  deal  with  it. 

Rare  and  special  complications  scarcely  require  mention.  The  most 
common  of  them  is  parotitis.  Mania  occurs  in  a  very  small  proportion 
of  cases.  Intestinal  fistula  caused  by  injury  to  bowel  at  the  operation, 
or  by  pressure  from  a  drainage  tube,  may  spontaneously  heal,  or  may 
require  operation.  The  occurrence  of  ventral  hernia  as  a  late  result 
should  be  very  rare  in  ovariotomy  if  the  closure  of  the  parietal  wound 
is  skilfully  effected.     Its  treatment  is  outside  the  scope  of  this  paper. 

Removal  of  the  Uterine  Appendages  (Oophorectomy :  Salpingo- 
Oophorectomy) .  —  l^y  this  operation  is  meant  removal  both  of  ovaries 
and  Fallopian  tubes  for  disease  other  than  neoplasm.  The  operation 
may  be  undertaken:  I.  When  the  appendages  and  the  uterus  are  normal; 
II.  When  the  uterus  is  affected  with  myoma;  III.  When  the  appendages 
are  in  a  state  of  inflammation.  Variations  in  the  method  are  described 
under  these  headings.  A  short  account  of  conservative  operations  on 
the  ovaries  aud  tubes  is  added. 

The  operation  is  prepared  for  as  in  ovariotomy ;  and  all  details  as  to 
room,  assistance,  ansesthesia,  and  nursing  are  identical.  The  Trendelen- 
burg posture  is  much  preferred  by  some  surgeons  for  this  operation. 

The  instruments  also  are  the  same,  except  that  tapping  trocars  and 
numerous  large  cyst-forceps  are  not  called  for.  Two  pairs  of  large  el- 
bowed pressure-forceps  aiul  a  dozen  ordinary  catch-forceps  are  necessary. 
In  cases  where  the  ai)])e)i(lages  are  bound  down  by  numerous  and  firm 
adhesions  in  Douglas'  pouch,  tlie  rectal  bag,  as  used  in  supra-pubic  cystot- 


OVARIOTOMY  905 


omy,  may  be  found,  very  useful  for  raising  the  field  of  operation  nearer 
to  sight  and  touch. 

Operation  ivith  Apioenclages  and  Uterus  Normal.  — The  incision,  which 
need  not  be  longer  than  an  inch  and  a  half  or  two  inches,  is  made  in 
the  middle  line  a  little  nearer  to  the  pubes  than  to  the  umbilicus.  The 
tissues  divided  are  the  same  as  in  ovariotomy.  As,  however,  the  parietes 
are  not  stretched  by  tumour,  the  linea  alba  is  narrow  ;  and  one  or  other 
rectal  sheath  will  probably  be  entered.  The  peritoneum  when  exposed 
is  picked  up  between  two  peritoneal  catch-forceps  and  pulled  forwards ; 
the  fold  between  them  is  sawed  through  by  a  knife  held  horizontally ; 
air  rushes  in  when  the  cavity  is  opened,  and  the  bowels  fall  back.  The 
left  forefinger  inserted  through  the  opening  serves  as  a  guide  on  which 
to  divide  with  scissors  the  peritoneum  to  the  whole  extent  of  the  parietal 
wound. 

The  first  and  second  fingers  of  the  left  hand  are  now  inserted  into 
the  cavity,  and  are  carried  straight  down  to  the  pelvis.  It  may  be  nec- 
essary to  push  omentum  upwards.  The  fingers,  displacing  intestines 
which  are  in  the  way,  seek  for  the  fundus  iiteri,  and  grasping  the  fun- 
dus betAveen  them,  they  are  slipped  along  one  or  other  broad  ligament, 
gathering  Fallopian  tube  and  ovary  in  their  grasp,  and  holding  them 
there.  These  are  now  lifted  out  through  the  parietal  wound,  and 
arranged  for  application  of  the  ligature.  The  parts  to  be  removed  are 
the  ovary,  with  its  mesovarium,  and  the  Fallopian  tube  in  its  outer 
three-fourths,  with  its  double  fold  of  peritoneum  or  mesentery ;  in 
which  also  lie  the  parovarium  and  the  vascular  tissue  known  as  the 
bulb  of  the  ovary. 

The  ligature  is  placed  by  transfixion.  The  Staffordshire  knot  is  per- 
fectly satisfactory  and  easily  applied.  The  pedicle-forceps  (Fig.  232)  is 
passed  through  the  broad  ligament  under  the  ovary  at  the  point  selected, 
and  catches  the  loop  of  silk  ligature,  placing  it  in  withdrawal.  Or  the 
ligature  may  be  passed  threaded  in  a  blunt  needle.  The  loops  being 
arranged  as  already  described  for  ovariotomy  (p.  889),  the  fingers  of 
the  left  hand  pull  ovary  and  tube  well  through  them,  Avhile  the  ends  are 
pulled  as  tightly  as  possible  by  the  right  hand.  Pressure  between  the 
left  finger  and  thumb  around  the  seat  of  ligation,  combined  with  traction 
on  the  ends  of  the  ligature,  serve  to  bury  the  ligature  in  the  tissues  ;  then 
it  is  tightly  tied  in  the  usual  way.  Forceps  or  the  fingers  of  an  assistant 
are  quite  unnecessary;  the  whole  may  be  done  in  a  few  seconds  by  the 
surgeon  unaided.  The  parts  are  then  cut  away  by  scissors  at  a  distance 
of  about  one-third  of  an  inch  from  the  ligature.  Before  division  is 
complete  a  catch-forceps  may  be  placed  on  the  stump  to  make  certain, 
by  pulling  it  to  the  surface,  that  hsemostasis  is  perfect  before  closing 
the  wound.  The  same  steps  are  carried  out  with  the  appendages  on  the 
opposite  side. 

Then  a  small  sponge  is  placed  under  the  parietal  opening,  tlie  sutures 
are  inserted,  the  sponge  is  removed,  the  stum]xs  are  pulled  up  by  their 
attached  forceps,  looked  at,  and  if  well  secured,  are  dropped  into  the 


9o6  SYSTEM  OF  GYNECOLOGY 

cavity,  and  the  sutures  in  the  parietal  wound  are  tied.  Tlie  wound  is 
dressed  as  in  ovariotomy. 

Operation  for  Uterine  Myoma.  —  In  the  case  of  small  tumours  the 
operation  may  be  the  same  as  that  just  described  with  normal  uterus. 

Where  the  tumour  is  large  or  fixed  in  the  pelvis,  or  where,  being  in 
the  fimdus,  it  grows  away  from  the  appendages,  the  operation  may 
present  considerable  difficulties,  or  may  even  be  surgically  impossible. 
In  unsymmetrical  tumours  one  ovary  may  be  near  to  the  siu-face  and 
quite  within  reach,  while  the  other  lies  deeply  or  out  of  reach.  In  all 
cases,  therefore,  before  removing  the  appendages  on  one  side  we  should 
ascertain  if  the  appendages  on  both  sides  can  be  removed.  It  frequently 
happens  that  an  ovary  is  much  stretched,  and  so  attenuated  as  to  be 
almost  undiscoverable;  sometimes  it  is  almost  buried  in  the  sulcus 
between  two  growths. 

AVhen  it  has  been  decided  to  remove  the  appendages,  the  tumour 
is  turned  to  one  side  so  as  to  bring  them  as  close  to  the  surface  as  pos- 
sible. At  this  stage  it  may  be  advisable  to  prolong  the  incision  upwards 
or  downwards  as  may  seem  more  convenient.  In  most  cases  the  incision 
will  have  been  made  longer  than  for  cases  with  normal  uterus.  If  pos- 
sible the  Staffordshire  knot  is  used :  but,  if  the  ovary  be  much  spread 
out,  a  double  or  triple  interlocking  ligature  may  be  preferred,  as  it 
is  possible  thus  to  get  more  thorough  constriction  over  a  larger  area. 
Forceps  are  left  attached  to  the  pedicle  first  made  while  the  uterus  is 
turned  to  the  opposite  side,  and  the  alternate  appendages  are  removed. 
A  sponge  placed  over  the  pedicle  prevents  disturbance  by  friction,  and 
calls  attention  to  the  existence  of  bleeding. 

It  would  seem  that  intestinal  obstruction  from  adhesion  of  bowel  to 
stump,  and  consequent  kinking,  is  more  liable  to  follow  removal  of  the 
appendages  for  myoma  than  for  other  disease.  The  intestine  seems 
liable  to  get  caught  between  tumour  and  pelvic  wall,  or  at  least  does  not 
freely  move  about  there ;  and  thus  the  formation  of  adhesions  is  favoured. 
To  avoid  this,  the  stump  may  be  turned  face-inwards  on  the  tumour,  and 
held  there  by  a  stitch;  its  raw  surface  then  becomes  adherent  to  the 
tumour :  or  it  may  be  covered  up  by  a  flap  of  peritoneum  left  hanging 
beyond  the  actual  line  of  division. 

Operation  with  Appendages  inflamed  and  adherent.  — Removal  of  the 
uterine  appendages,  when  matted  together  and  adherent  to  neighbouring 
organs,  and  perhaps  containing  one  or  more  collections  of  pus,  may  be 
a  very  difficult  operation.  A  good  many  cases  are  recorded  where  the 
operation  was  either  abandoned  as  impracticable  or  was  left  incompleted. 

The  operation  is  performed  either  by  the  help  of  sight  or  by  touch 
alone  without  exposure  to  view.  If  the  diseased  organs  are  to  be 
exposed  to  view,  a  long  incision  and  either  evisceration  of  intestines, 
or  pushing  them  into  the  upper  abdomen,  are  necessary.  For  this  the 
Trendelenburg  posture  with  great  elevation  of  the  pelvis  should  be 
adopted.  The  use  of  the  rectal  bag  to  raise  the  pelvic  floor  is  also  of 
assistance.     Strong  retractors,  or  Maunsell's  self-acting  retractor,  are 


OVARIOTOMY  907 


necessary  to  keep  the  parietal  incision  open ;  and  artificial  light  Avith 
or  without  concave  nairrors  may  be  required. 

This  method  of  operating  has  not  found  favour  in  England.  If  the 
parietes  are  muscular  and  hard,  it  is  not  easy  to  crowd  the  intestines 
into  the  upper  abdomen ;  and  considerable  force  may  be  required  to  keep 
the  incision  sufficiently  open  to  give  a  fair  view  of  the  parts  while 
manipulation  is  going  on.  The  incision  itself  must  be  of  considerable 
length,  five  or  six  inches  perhaps;  and  this  means  in  an  undistended 
abdomen  that  it  reaches  the  umbilicus,  or  even  rises  above  it. 

It  is  best  to  depend  entirely  on  the  fingers  for  removal  of  adherent 
appendages.  The  skilled  sense  of  touch  is  a  safe  guide  against  the  risk 
.of  tearing  bowel  or  other  attached  structures,  and  the  fingers  are  strong 
enough  to  detach  any  adhesions  which  are  likely  to  be  met  with. 

The  incision  is  made  in  the  ordinary  way,  and  may  be  about  three 
inches  in  length.  A  little  cloudy  or  pink  serum  often  appears  in  the 
incision ;  not  unfrequently  there  is  a  considerable  amount  of  ascites. 
The  first  and  second  fingers  of  the  left  hand  are  carried  to  the  fundus 
uteri,  thence  into  Douglas'  pouch,  and  along  both  broad  ligaments ;  and 
the  state  of  affairs  accurately  made  out.  If  there  be  any  collections  of 
fluid,  purulent  or  sanguineous,  it  is  wise  at  once  to  place  a  fiat  sponge 
in  the  pelvis  to  prevent  contamination  in  case  the  cyst-wall  is  ruptured. 
It  is  often  almost  impossible  to  separate  and  deliver  entire  an  abscess 
with  very  thin  walls ;  a  sponge  to  surround  the  field  of  operation 
minimises  the  risks  from  rupture  and  diffusion. 

The  work  of  separation  is  now  begun.  Detachment  is  begun  from 
below,  the  inflamed  organs  being  unfolded  upwards  as  the  adhesions  are 
separated.  The  firmest  adhesions  are  usually  to  the  posterior  surface 
of  the  broad  ligaments,  and  here  bleeding  is  likely  to  be  most  free. 
Adhesions  to  the  rectum  must  be  separated  with  great  care  to  avoid 
laceration  of  the  wall  of  the  bowel. 

The  presence  of  the  rectum  bag  moderately  distending  the  gut  guides 
the  finger  in  its  movements,  and  helps  to  give  some  idea  of  the  thickness 
of  its  wall  from  which  the  organs  are  being  detached.  Adhesions  to 
the  uterus  are  more  easily  managed,  although  the  bared  surface  may 
bleed  freely.  Into  the  spaces  made  after  detachment  the  sponge  is 
dragged,  or  new  sponges  are  placed.  This  sponge-packing  is  a  measure 
of  safety  in  case  of  extravasation,  a  guide  to  a  source  of  bleeding,  and 
an  absorbent  of  blood.     It  is  also  useful  as  a  haemostatic. 

When  the  organs  are  detached  they  are  pulled  to  the  surface  through 
the  wound.  Often  they  are  quite  sessile  on  the  broad  ligament,  and 
some  force  may  be  necessary  to  bring  them  within  sight.  Such  force 
is  exerted  not  by  dragging  on  the  organs  themselves  but  on  their  pedicle 
held  between  the  two  fingers.  Liberation  may  be  assisted  by  pushing 
down  the  broad  ligament  at  its  pelvic  attachment;  tearing  or  stretching 
its  fibres,  but  not  wounding  its  peritoneal  envelopment. 

Frequently  the  pedicle  must  be  tied  at  some  distance  from  the  surface. 
By  depressing  the  parietes  and  pulling  the  organs  well  up  into  the  wound 


9o8  SYSTEM   OF  GYNECOLOGY 

this  may  usually  be  done  within  sight,  but  sometimes  the  pedicle  must 
be  tied  and  divided  entirely  by  touch.  The  ligature  is  placed  by  trans- 
fixion and  tied,  as  already  described,  either  in  a  Staffordshire  knot  or  in 
interlocking  ligatures.  The  organs  on  the  other  side  are  detached  and 
removed  in  the  same  way. 

Bleeding  in  these  cases  is  sometimes  very  free,  and  occasionally 
alarming.  By  sponge-packing  and  pressure  it  may  usually  be  checked 
in  a  few  moments,  and  no  bleeding  points  require  forcipressure  or  liga- 
tion. If  it  continue,  bleeding  points  should  be  looked  for  through  a 
Fergusson's  vaginal  speculum  ;  or,  if  this  means  fail,  the  wound  must  be 
enlarged  and  the  pelvic  floor  exposed.  The  Trendelenburg  position  is 
here  of  some  advantage.  A  solution  of  iodine  or  of  perchloride  of  iron, 
may  be  mopped  over  a  bleeding  surface,  or  the  actual  cautery  may  be 
applied.  Bleeding  points  are  caught  in  forceps,  which  are  left  on  for  a 
few  moments  while  the  cavity  is  cleansed  and  the  sutures  are  placed. 
Forceps  placed  on  the  rectum  may,  if  too  large  a  hold  has  been  taken, 
result  in  the  formation  of  a  slough  followed  by  fistula. 

The  pelvis  should  be  carefully  cleansed  by  sponging  or  irrigation,  or 
both,  according  to  the  nature  and  amount  of  extravasation.  Sponging 
will  usually  suffice  if  blood  only  has  to  be  removed ;  indeed  most  of  the 
blood  will  be  removed  with  the  sponges  which  have  been  packed  into 
the  wounded  areas.  Irrigation  must  be  employed  if  fluids  of  a  putrid 
or  doubtful  nature  have  escaped. 

Drainage  is  advisable  in  most  of  these  cases.  Through  the  tube 
bleeding  gives  timely  warning  of  its  onset ;  and  through  it  the  abdomen 
can  be  kept  dry,  which  in  itself  favours  clotting  and  haemostasis.  In 
cases  of  free  bleeding  the  use  of  the  gauze  drain,  or  of  gauze-packing, 
may  be  necessary.  But  everything  possible  should  be  done  to  render 
hsemostasis  perfect  by  the  ordinary  surgical  means  before  having  recourse 
to  such  uncertain  methods  as  these. 

Keith's  glass  drainage-tube  with  open  extremities  is  usually  the  best. 
The  tube  should  reach  to  the  bottom  of  Douglas'  pouch,  and  should  be 
supported  by  the  collar  outside  the  wound,  and  not  by  the  rectum. 
Pressure  on  the  rectum  by  the  tube  may  cause  the  production  of  intestinal 
fistula.  Gauze  or  thread  capillary  drains  are  placed  inside  the  tube, 
and  the  absorbent  dressing  is  placed  over  the  tube  enclosed  in  a  folded 
sheet  of  india-rubber  through  which  the  upper  end  of  the  tube  is  drawn. 
The  drainage-tube  in  most  cases  may  be  removed  in  a  day  or  two;  but 
some  cases  require  drainage  for  a  week  or  even  longer. 

Where  there  is  a  large  pyosalpinx  or  ovarian  abscess  it  is  generally 
advisable  to  empty  the  fluid  by  aspiration  before  beginning  to  separate 
adhesions.  This  diminishes  risk  from  escape  of  fluid,  but  adds  to  the 
difficulty  of  separation  by  fingers. 

The  wound  is  dressed  and  the  patient  is  treated  exactly  as  after 
ovariotomy.  Usually  there  is  more  pain  than  after  ovariotomy,  and 
constitutional  disturbance  with  rise  of  tem]jerature  may  be  more  marked. 
Pain  severe  enough  to  cause  great  restlessness  or  jactitation  may  be 


OVARIOTOMY  909 


alleviated  by  a  hypodermic  injection  of  morpliia ;  but  the  recovery  is 
nearly  always  more  rapid  and  satisfactory  if  morphia  is  withheld. 
Metrorrhagia  nearly  always  comes  on  after  one  or  two  days  ;  this  gives 
relief  and  requires  no  treatment. 

Conservative  Operations  on  the  Ovaries  and  Tubes.  — Till  the  last  few 
years  the  generally  expressed  opinion  of  the  most  experienced  opera- 
tors —  that  it  is  best  to  remove  diseased  ovaries  and  tubes  completely 
—  has  been  received  and  acted  upon.  A  few  surgeons  have  recently 
maintained,  and  proved  by  records  of  successful  cases,  that  destructive 
surgery  is  not  always  necessary  for  cure  ;  but  that  conservative  opera- 
tions, leaving  the  organs  or  some  part  of  them  intact,  may  be  followed 
by  cure.  This  has  been  maintained  in  respect  not  only  of  inflammatory 
conditions  and  hernia,  but  also  of  tumours  and  cysts. 

In  respect  of  tumours,  Martin  of  Berlin,  Sippel,  and  Pozzi  have  been 
the  chief  advocates  of  conservatism.  If,  near  the  hilum,  a  portion  of 
healthy  ovarian  tissue  be  visible,  this  is  left,  and  the  incised  surfaces 
are  apposed  and  fixed  by  sutures.  Pregnancy  resulted  in  a  case  of 
Sippel's  where  one  ovary  affected  with  a  small  growth  was  so  treated ; 
the  other  ovary  being  completely  removed  for  a  large  growth.  Martin, 
in  twenty-seven  cases  in  which  portions  of  healthy  ovary  were  left,  had 
one  death  and  two  relapses ;  eight  of  the  patients  bore  children  after- 
wards. Pozzi,  in  twelve  cases  of  resection  of  the  diseased  portion  alone, 
speaks  favourably  of  the  operation.  Other  surgeons  have  mentioned 
cases,  but  have  been  cautious  in  drawing  conclusions. 

In  cases  of  simple  cysts  treatment  by  simple  puncture,  or  by  removing 
the  whole  of  the  cyst-walls  by  scissors,  is  undoubtedly  sound.  ]\Iost 
surgeons  would  probably  agree  in  this  practice. 

In  the  case  of  abscess  there  is  more  room  for  dispute.  Simple 
evacuation  of  the  abscess  with  cleansing  of  the  abscess  wall  would,  in 
carefully  selected  cases,  probably  be  entirely  satisfactory.  One  difliculty 
is  to  be  certain  that  the  abscess  is  single,  for  abscesses  in  glandular 
organs  are  liable  to  be  multiple ;  and  another  is  to  be  certain  that  the 
abscess  wall  is  rendered  sterile.  Drainage,  except  in  large  abscesses,  is 
not  feasible  at  a  distance  from  the  surface  ;  and  if  it  were  so  employed  it 
would  leave  the  organ  in  a  bed  of  adhesions  which  would  probably  beget 
chronic  invalidism  of  another  sort.  The  most  satisfactory  results  would 
be  in  a  peripheral  abscess  with  comparatively  thin  walls,  where  the  whole 
sac  might  be  cut  away,  and  the  cavity  left  might,  after  purification,  be 
closed  up  by  sutures.  A  central  abscess  with  general  distension  of  the 
whole  ovarian  tissue  could  scarcely  so  be  treated,  and  is  probably  best 
treated  by  removal  of  the  whole  organ.  There  is,  theoretically,  no  need 
to  remove  a  healthy  Fallopian  tube  with  a  suppurating  ovar}' ;  but  experi- 
ence proves  that  healthy  tubes  Avith  sup^mrating  ovaries  are  the  rarest  of 
combinations.  The  tulie  is  useless  without  its  ovary ;  the  ligature  of  the 
ovarian  pedicle  will  probably  cause  injury  or  kinking  of  the  tube :  there- 
fore, if  the  ovary  be  removed,  it  is  usually  safer  for  recovery  from  the 


9IO  SYSTEM   OF  GYNECOLOGY 

operation,  and  for  the  future  comfort  of   the  patient,  to  remove   the 
tube  also. 

The  removal  of  the  appendages  on  one  side  only  for  suppurative 
disease  "n-as  tried  by  Tait,  but  given  up  on  account  of  the  large  number 
of  recurrences  or  relapses.  Other  surgeons  have  had  similar  experiences  ; 
and  the  rule  in  all  cases  of  suppurative  disease  of  the  appendages  now  is 
that  if  one  set  is  removed  so  also  should  be  the  other. 

More  promising  results  have  been  got  in  the  conservative  treatment 
of  chronic  inflammatory  disease  with  adhesions,  but  without  suppuration. 
Liberation  of  the  organs  with  removal  of  long  tags  of  adhesions  and  per- 
haps puncture  of  cysts  may  result  in  cure.  In  most  of  such  cases  there 
is  prolapse  ;  to  remedy  this  operative  elevation  of  the  ovary  on  the  broad 
ligament  by  shortening  its  mesentery  has  been  jjractised.  Of  the  real 
and  permanent  value  of  oophororaphy  or  oophoropexy  published  records 
do  not  permit  us  to  judge;  but  there  can  be  no  doubt  of  the  advantage 
of  the  liberation  of  an  ovary  bound  down  by  adhesions  in  Douglas' 
pouch  or  elsewhere. 

Hernia  of  the  appendages  into  the  inguinal  or  femoral  canals  may, 
even  if  strangulated,  be  properly  treated  by  return  into  the  cavity  of  the 
abdomen,  provided  the  hernial  openings  be  closed.  Tubo-ovarian  herniae 
are  nearly  always  inguinal ;  tubal  hernia  is  with  about  equal  frequency 
femoral  and  inguinal.  A  strangulated  tube  is  not  unlikely  to  contain  one 
or  several  collections  of  pus  ;  its  return,  therefore,  should  be  carried  out 
only  after  minute  examination.  A  probe  may  be  passed  along  it,  or 
puncture  or  other  means  adopted  to  make  certain  of  the  absence  of 
suppuration.  For  most  cases  of  strangulation  of  tubes  operation  by 
removal  is  generally  considered  most  satisfactory.  The  method  of  radi- 
cal cure  of  the  hernia  to  be  adopted  need  not  be  described. 

Tubercular  disease  of  the  tubes  should  always  be  treated  by  complete 
removal. 

Simple  cysts  of  the  Fallopian  tubes  may  be  cured  by  incision,  with 
partial  removal  of  the  cyst-walls.  But  in  respect  of  restoration  of 
function,  such  an  operation  has  no  advantages  over  complete  removal, 
and  has  evident  disadvantages  in  the  possibility  of  recurrence  with 
stenosis  of  the  tube. 

J.  Gkeig  Smith. 

REFERENCES 

1.  Chambon.  Das  maladies  cles  femmas,  Paris,  1784 ;  anrl  Da  I'extirpation  des 
ovaires.  Paris,  1798. — 2.  Clay.  Casas  of  Peritoneal  Saction  for  Extirpation  of  Diseased 
Ovaries.  Lund.  1842.  —  3.  Uklaporte.  Mdm.  de  I' Acad.  Roy.  de  (Jhir.  Paris,  1753. 
—  4.  HuNTKR.  Med.  Observations  Inquiries,  \o\.\\.  Lond.  17()2. —  5.  Kelly,  Howard, 
Amer.  Jour.  Ob.Htet.  xxiv.  12,  1890.  — (i.  King  and  Jeafkrkson.  Lancet,  l^ond.  1856-7, 
i.  588-.'J90. — 7.  M'DowKLL,  E.  "  T]ire(!  Cases  of  Exlirjiatioii  of  Diseased  Ovaria," 
Eelect.  Report,  Pliiia.  1817,  vii.  242-244.  (From  Index-Catalogue  of  Lil)rary  of  Snrgeon- 
General's  offiee,  WashitiKf.on.)  — 8.  Martin.  Deutsch.  mod.  Woch.  July '27,  189:5.  — 9. 
Pozzi.  Ann.  de  r/yn.  et  (I'oh.stdt.  Marcli  189.'5.  — 10.  Sippel.  (Jentralbl.  f.  Gyniik.-iW. 
189.'5.  — 11.  Tait,  i.AwsoN.  Diseaxes  of  the  Ovarien,  M\\  c(\.  Birm.  1883.  — 12.  Wells, 
Sir  Spencer.  Disan.'ies  of  the  Ovaries,  Lond.  1872;  Abdominal  Tnmours.  7th  ed. 
Loud.  1887.  — 13.   Willius.     Stupendus  abdominis  Tumour,    Uasil,  1731. 


CHRONIC  INVERSION  OF  THE  UTERUS  911 

Special  Works  and  Articles  on  Ovariotomy.  —  1.  Atlee,  W.  S.  Diagnosis  of 
Ovarian  Tumours.  Phila.  1873.  —  2.  Baker-Brown.  On  Ovarian  Dropsy.  Lond. 
1862. — 3.  Clay.  Cases  of  Peritoneal  Section  for  Extirpation  of  Diseased  Ovaries. 
Lond.  1842. — 4.  Courty,  A.  Diseases  of  the  Uterus,  Ovaries,  and  Fallopian  Tubes. 
Trans,  from  3rd  edit,  by  A.  M'Laren.  Lond.  1882. —5.  Doran,  A.  H.  G.  Tumours 
of  the  Ovary,  Fallopian  Tube,  and  Broad  Ligament.  Lund.  1884.  —  ti.  Ibid.  Gynseeo- 
logical  Operations.  Lond.  1887.  —  7.  Keith,  Skene  and  G.  E.  Abdominal  Surgery. 
Edin.  1894. — 8.  Koeberli5.  Sur  le  traitement  des  kysles  de  I'ovaire.  Paris  18t)."). — y. 
Ibid.  Manuel  operatoire  de  Vovariotomie.  Paris,  1870.  — 10.  Lizars,  J.  Observations 
on  Extraction  of  Diseased  Ovaria.  Ediu.  1825.  — 11.  Peax,  J.  Tumeurs  de  V abdomen 
et  du  bassin.  Paris,  1895.  — 12.  Peaslee.  Ovarian  Tumours.  New  York,  1872. — 
13.  Smith,  J.  Greig.  Abdominal  Surgery,  5th  ed.  Lond.  1896.  — 13.  Sutton,  J. 
Bland.  Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes.  Lond.  1896.  — 14. 
Tait,  Lawson.  Diseases  of  the  Ovaries,  4th  ed.  Birm.  1883. — 15.  Wells,  Sir 
Spencer.  Diseases  of  the  Ovaries.  Lond.  1872.  — 16.  Ibid.  Abdominal  Tumours,  7th 
ed.    Lond. 1887. 

1.  System  of  Gynecology  and  Obstetrics  by  American  Authors.  Edited  by  M.  D. 
Mann  and  B.  C.  Hirst.  "  Gynrecology."  Edin.  1889,  ii.  1S9  et  seq.  —  2.  An  American 
Text-Book  of  Gynxcology.  Ed.  by  J.  M.  Baldy.  Phila.  1894,  pp.  594-600.  — 3.  Clinical 
Gynecology  by  American  Teachers.  Edited  by  J.  M.  Keating  and  H.  C.  Coe.  Edin. 
1895,  p.  697  et  seq. — 4.  Pepper's  Syst.  Pract.  Med.  "  Dis.  of  Ovaries  and  Oviducts" 
(Skene),  1886,  vol.  iv.  —  5.  International  Encyc.  Surg.  Ed.  by  Ashurst,  Lee,  1886, 
vol.  vi. 

J.  G.  S. 


CHRONIC   INVERSION   OF  THE   UTERUS 

Inversion  of  the  uterus  has  been  a  favourite  theme  for  essays.  It  is  a 
condition  attended  with  considerable  anxiety,  impaired  health,  and  danger 
to  life.  Its  occurrence  is  far  from  common :  eminent  consultants  of 
exceptional  experience  have  never  met  wnth  it ;  practitioners  engaged  in 
large  midwifery  practice  have  never  seen  a  case.  It  was  found  at  the 
Rotunda  Hospital  once  in  190,800  deliveries.  At  the  Vienna  Lying-in 
Hospital  250,000  births  occurred  without  a  single  instance.  With  access 
to  records  of  over  20,000  labours  I  have  met  with  one  case  of  recent 
inversion ;  and  in  twenty-five  years'  practice  two  instances  only  of 
chronic  inversion  have  come  under  my  own  care.  Possibly  it  has  hap- 
pened without  recognition,  or  at  any  rate  without  publication,  where 
close  inquiry  was  not  practicable. 

Inversion,  as  the  name  implies,  is  the  uterus  turned  inside  out;  the 
lining  mucous  membrane  becomes  external,  the  serous  peritoneal  mem- 
brane internal. 

It  may  be  puerperal  or  non-puerperal :  in  the  former  it  is  associated 
with  labour  or  is  the  result  of  pregnancy ;  in  the  latter  it  is  allied  with 
certain  tumours  or  growths  in  the  non-pregnant  uterus.  The  puerperal 
condition  is  responsible  for  the  great  majority  of  cases,  as  many  as  87-5 
per  cent.  Most  of  these  happen  at  or  near  the  termination  of  labour. 
Of  the  224  cases  collected  by  Crampton,  196  are  noted  as  having  occurred 
at  once ;  that  is,  at  the  end  of  the  process  of  confinement.     It  follows 


912  SYSTEM  OF  GYNAECOLOGY 

that  a  division  into  acute  and  chronic  is  admissible,  the  distinction 
being  based  upon  the  completion  of  the  involution  of  the  uterus ;  that 
is,  about  six  weeks  from  the  date  of  labour. 

In  the  puerperal  variety,  therefore,  inversion  of  the  uterus  may  be 
looked  upon  as  chronic  when  it  persists  after  the  regenerative  changes 
which  are  normally  effected  after  delivery.  The  usual  reconstitution  of 
the  uterus  may  be  retarded  or  perverted  by  the  conditions  present  in  any 
given  case;  but  the  interval  of  time  forms  a  valid  ground  for  definition 
and  for  treatment.  Chronic  inversion  is  a  sequence,  then,  of  the  acute 
form ;  and  is  due  to  failure  of  reduction  before  the  time  allowed  for 
reparation  of  the  puerperal  uterus.  Chronic  inversion  further  includes 
cases  occurring  independently  of  pregnancy  ;  those  which  happen  as  a 
complication  of  some  tumours,  or  of  some  growths  in  the  uterine  walls, 
malignant  or  otherwise. 

Anatomy  and  Pathology. — Various  degrees  of  inversion  are  described. 
According  to  Crosse,  partial  inversion  in  its  slightest  degree  is  present 
Avhen  any  portion  of  the  entire  thickness  of  the  walls  of  the  uterus  becomes 
convex  towards  its  cavity  or  interior ;  although  it  may  not  be  invaginated, 
or  brought  within  the  grasp  of  the  rest  of  the  uterus.  It  may  accompany 
the  projection  of  a  tumour  into  the  cavity;  thus  the  peritoneal  space  has 
been  opened  in  dividing  the  base  of  a  tumour  for  its  removal.  One  horn 
of  the  uterus  may  occasionally  be  indented.  In  cases  of  post-partum 
haemorrhage,  with  a  large  and  flabby  uterus  —  especially  where  efforts  are 
made  by  external  pressure  to  force  the  uterus  into  contraction  —  we  not 
infrequently  find  the  wall  to  yield  and  partial  depression  to  follow.  This 
is  more  likely  to  occur  when  the  hand  is  pressed  against  the  uterus, 
instead  of  grasping  it  after  the  method  of  Crede.  In  this  way,  as  the 
placenta  is  expelled,  the  fingers  may  pursue  it  into  a  hollow,  which 
the  contraction  of  the  whole  uterus  generally  readjusts  at  once. 

The  body  of  the  uterus  may  be  inverted  as  far  as  the  os  internum ; 
or  there  may  be  complete  inversion  of  the  body  through  the  cervix  into 
the  vagina,  or  even  externally.  Generally  the  cervix  remains,  forming 
a  distinct  fold  or  ridge  around  the  neck  of  the  inversion.  This  fold 
varies  in  depth  according  to  the  extent  in  which  the  cervix  is  involved. 
As  a  rule  it  is  rather  deeper  in  front  than  behind.  When  the  uterus 
descends  externally  it  is  usually  accompanied  by  inversion  of  the  vagina ; 
the  cervix  also  participates,  and  the  depression  formed  by  the  ring  may 
not  be  found. 

The  form  of  the  inverted  uterus  is  round  or  pear-shaped,  with  a  well- 
formed  but  smaller  base.  The  shape  varies  somewhat  according  to  the 
degree  of  inversion  and  the  pressure  to  which  it  is  subjected  by  the 
constricting  ring  of  the  cervix ;  or,  when  lower  down,  by  the  opposing 
contact  of  the  vaginal  walls. 

The  same  circumstances  affect  the  consistence  and  colour.  It  may  be 
firm  and  tense,  softer  and  more  yielding,  smoother  and  more  velvety  to 
the  touch.  The  surface  of  the  mucous  membrane  may  be  red,  or  congested 
and  purple;  usually  it  is  less  pink  than  that  of  the  fibroid.     It  may 


CHRONIC  INVERSION  OF   THE    UTERUS  913 

present  ecchymosed  spots,  or  show  erosions  and  ulcerations  which,  in  few 
instances,  have  formed  adhesions  to  opposite  surfaces  of  the  cervix  of 
vaginal  walls.  It  bleeds  freely  when  handled.  When  the  inverted  sur- 
face is  exposed  for  any  length  of  time  to  the  air  the  mucous  membrane 
may  lose  its  normal  characteristics,  and  become  dry  and  wrinkled  like 
that  of  a  procident  vagina.     The  two  have  indeed  been  confounded. 

Inflammation  and  even  gangrene  have  followed  the  arrest  of  blood- 
supply  and  the  perverted  nutrition  due  to  the  incarceration ;  and  in 
some  rare  instances  sloughing  of  the  inverted  portion  has  taken  place. 

The  peritoneal  invagination  contains,  at  the  beginning,'  the  broad  and 
round  ligaments,  the  Fallopian  tubes,  and  the  ovaries.  Sometimes,  at  the 
first  rush,  a  loop  of  small  intestine  is  drawn  into  the  cavity.  After  a 
time,  when  contraction  takes  place,  the  ovaries  and  tubes  recede  outside 
the  space ;  and  the  margin  of  the  opening  remains  as  a  firm  ring  into 
which  the  finger  can  hardly  pass.  It  rarely  happens  that  an}^  adhesion 
takes  place  between  the  peritoneal  surfaces,  though  this  has  occurred. 

In  cases  of  non-puerperal  origin,  Avhen  the  formation  of  the  inversion 
is  more  gradual,  part  only  of  the  Fallopian  tubes  and  broad  ligaments 
are  found  in  the  interior  space. 

Mechanism  of  Production.  —  Inversion  begins  generally  at  the  fundus; 
occasionally  at  the  sides,  posteriorly,  or  at  the  cervix. 

It  lias  long  been  considered  that  enlargement  of  the  uterine  cavity, 
associated  with  some  cause  capable  of  exciting  contraction  of  its  fibres, 
are  the  two  conditions  essential  to  inversion.  That  the  uterus  often  con- 
tracts irregularly,  one  part  being  firm,  another  relaxed,  is  well  known. 
The  state  spoken  of  as  polarity,  when  the  fundus  is  contracted  and  the 
cervix  dilated,  or  conversely,  is  an  observed  fact  supposed  to  be  due  to 
some  correlation  of  nerve  force. 

Most  authors  speak  of  the  important  part  taken  by  modifications  in 
the  placental  site  as  a  factor  causing  inversion.  The  wall  of  the  uterus 
at  this  part  is  thinner  and  more  lax ;  its  structure  is  modified ;  it  is 
generally  more  yielding  and  of  less  power.  Klob  says  defective  con- 
traction of  that  part  of  the  uterine  wall  which  forms  the  placental 
insertion  is  of  extraordinary  importance;  and  he  describes  it  as  sink- 
ing inward  into  the  uterine  cavity  while  other  parts  of  the  organ  seem 
tolerably  well  contracted. 

Rokitansky  speaks  of  paralysis  of  the  placental  insertion  as  originat- 
ing depressions  in  connection  with  irregular  contractions  of  the  other 
parts  of  the  uterus. 

iMatthews  Duncan  devoted  special  attention  to  this  subject,  and  formu- 
lated his  views  respecting  it  with  much  emphasis.  His  views  appear  to 
be  the  outcome  of  a  concise  and  logical  interpretation  of  facts  which  afford 
a  rational  ex])lanation  of  the  phenomena  observed.  He  divides  inversion 
after  delivery  into  active  and  passive,  and  describes  four  kinds :  (A.) 
Passive :  (i.)  Spontaneous,  and  (ii.)  Artificml     (B.)  Active :  (iii.)  Sjwntane- 

1  Sveiisson  amputatod  one  three  months  after  delivery,  and  found  in  the  extirpated  mass 
both  tlie  ovaries  and  the  greater  portion  of  the  broad  ligament  (Sajous,  1889,  i.  p.  2'.^). 

3n 


914  SYSTEM  OF  GYNECOLOGY 

ous,  and  (iv.)  Artificial.  The  condition,  he  says,  essential  to  the  production 
of  all  these  kinds,  and  the  only  one,  is  paralysis  or  inertia,  or  complete  in- 
action. Such  is  the  condition  of  the  whole  organ  at  the  time  of  production 
of  the  first  two  kinds :  in  the  last  two  kinds  the  accident  is  accom- 
panied by  uterine  activity,  but,  as  these  cannot  exist  in  the  same  part,  the 
paralysis  is  partial,  and  the  activity  is  partial.  He  affirms  that  activity 
of  the  whole  of  the  uterus,  or  of  its  body,  renders  inversion  impossible. 

Force  may  be  applied  from  above  to  push  the  paralysed  wall  into  the 
uterine  cavity ;  or  from  below  to  pull  it  into  the  cavity.  In  the  spon- 
taneous kinds  it  is  to  be  found  in  the  mechanical  conditions  of  the 
abdomen,  in  the  ordinary  down-bearing  effort,  or  in  the  absence  of  the 
retentive  power  of  the  cavity  however  produced.  In  connection  with 
the  artificial  kinds  I  may  refer  to  cases  where  the  cause  is  to  be  found 
in  pulling  upon  the  cord  —  "  manoeuvring  with  the  placenta,"  as  Mat- 
thews Duncan  aptly  terms  it.  No  doubt  when  the  attachment  of  the 
placenta  is  to  the  fundus,  the  disposition  to  inversion  is  aggravated  by 
traction. 

On  the  whole,  it  may  be  considered  that  traction  of  the  cord  as  a  cause 
of  this  accident  is  overrated,  especially  in  modern  times  when  better 
knowledge  commands  more  accurate  management  of  the  third  stage  of 
labour.  Shortness  of  the  cord,  whether  in  length  or  from  coiling,  has  not 
the  importance  formerly  attributed  as  a  cause;  unless  indeed  the  labour 
be  precipitate  or  the  patient  rapidly  delivered  in  the  upright  position. 

Spontaneous  active  inversion  is  probably  the  most  common  kind : 
paralysis  of  a  portion  of  the  fundus  or  placental  portion  leads  to  the 
depression;  the  paralysed  projecting  part  is  further  seized,  pushed 
down,  and  expelled  by  the  contracting  parts  through  the  os  uteri  or 
into  the  vagina. 

That  inversion  may  begin  at  the  cervix  has  been  clearly  demonstrated 
by  Dr.  Taylor  of  New  York  in  a  case  of  his  own;  in  that  of  Reeve  and 
others  the  condition  began  by  eversion  of  the  os,  and  rolling  of  the  body 
and  fundus  out  of  the  cervix. 

Dr.  Duncan  admits  that,  under  powerful  contraction  of  the  fundus 
and  relaxation  below  that  x^art,  inversion  of  the  lower  part  of  the  cervix 
may  occur  alone ;  and  he  says  that  it  is  not  rarely  observed  after  delivery. 
He  depicts  diagrammatically  the  extent  to  which  the  change  may  go  in 
the  direction  of  inversion ;  but  does  not  say  that  he  has  seen  it  occur 
in  the  complete  degree  observed  by  Dr.  Taylor.  That  spontaneous 
inversion  of  the  nulliparous  uterus  can  take  place  has  been  strongly 
denied.  The  case  recorded  by  Dr.  Taylor  is  a  clear  instance  in  the 
proof  of  its  occurrence ;  other  instances  recorded  by  careful  and  com- 
petent observers  render  it  indisputable  that  such  an  event  may  happen. 

Etiology.  —  In  the  first  place  the  changes  coincident  with  pregnancy 
and  parturition  undoubtedly  have  the  largest  share  in  disposing  to  this 
accident.  V>y  far  the  greater  nuinl)er  of  cases  occur  in  primijjaraj.  In 
Crampton's  collection  of  cases  S8  out  of  17G  were  after  first  labours.  It 
rarely  happens  in  conjunction  with  abortion  or  miscarriage. 


CHRONIC  INVERSION  OF   THE    UTERUS  915 

Conditions  in  sonie  respects  analogous  to  pregnancy  also  act,  though 
much  more  rarely,  as  disposing  causes. 

Distension  of  the  cavity  and  relaxation  of  the  walls  of  the  uterus  are 
important  factors  in  the  event.  Deficiency  in  muscular  tone  and  irregular 
or  imperfect  contraction  tend  to  favour  its  production. 

In  Avonien  of  feeble  and  lymphatic  constitution,  more  particularly  after 
severe  haemorrhage  when  the  uterus  is  limp  and  flaccid,  the  liability  is 
greater.  Some  individual  peculiarity  is  also  exhibited  in  those  women 
in  whom  inversion  has  taken  place  in  successive  confinements. 

Inversion  occurs  after  abortion,  in  rare  cases ;  generally  as  the  result 
of  some  applied  force  or  accident. 

In  the  presence  of  morbid  growths  affecting  the  structure  of  the  uterus 
there  is,  as  a  rule,  dilatation  of  the  interior.  This  is  likewise  to  be  noted 
in  the  case  of  tumours  growing  inwards,  more  so  when  attached  to  the 
fundus.  Of  the  400  cases  given  by  Crosse  50  are  noted  as  connected 
with  tumours.  Pediculated  fibroids  are  the  most  common ;  with  these 
it  may  occur  spontaneously ;  or  again,  after  removal  of  an  intra-uterine 
tumour  with  a  broad  attachment.  Some  alteration  in  the  walls  of  the 
uterus  at  the  site  of  the  growth,  contractions  at  the  menstrual  periods, 
and  intra-abdominal  pressure  are  the  usual  associations  which  cause  the 
body  to  be  projected  through  the  cervix.  In  sarcoma  this  is  more  fre- 
quent :  Dr.  A.  R.  Simpson  met  with  it  in  4  cases  out  of  48.  It  rarely 
occurs  with  epithelial  carcinoma.  Dr.  Barnes  mentions  two  cases. 
Distension  by  fluids  or  retained  secretions  is  more  uniform  and  gradual ; 
in  the  absence  of  any  weakened  spot  or  external  force  the  tendency  of 
the  walls  to  give  way  is  less  localised. 

Symptoms.  —  When  this  event  occurs  suddenly  and  completely  in  its 
puerperal  form  the  symptoms  are  those  of  profound  shock  and  collapse, 
accompanied  by  intense  pain  and  haemorrhage.  The  pain  is  fixed  and 
persistent ;  the  bleeding  continuous  and  profuse.  The  absence  of  the 
uterus  from  its  normal  position  will  remove  all  doubt  as  to  the  nature 
of  the  accident. 

In  the  partial  form  the  symptoms  are  not  so  characteristic ;  indeed, 
unless  a  thorough  examination  be  made  at  the  time,  the  accident  may 
escape  observation. 

In  chronic  inversion  the  symptoms  are  anaemia  and  impaired  health; 
irregular  haemorrhages,  often  profuse ;  discharges ;  sometimes  urinary 
troubles ;  local  pain  and  discomfort ;  diffici;lty  in  walking.  In  this 
way  women  have  been  known  to  drag  on  a  miserable  existence  for  many 
years,  and  die  ultimately  of  exhaustion,  peritonitis,  or  septicemia.  In 
some  instances,  however,  patients  have  reached  advanced  age  Avithout 
any  discomfort  and  even  without  knowledge  of  their  ailment ;  and  others 
have  suffered  little  more  than  inconvenience  from  the  displacement. 
Such  immunity  has  generally  been  in  women  who  have  passed  the 
climaoteric  ])oriod. 

Diagnosis.  —  In  a  simple  case  the  diagnosis  is  easy.  In  complex 
cases  definite  diairnosis  is  sometimes  attended  with  difficulties  which  even 


916  SYSTEM   OF  GYN.-ECOLOGY 

accomplished  experts  have  not  been  able  to  overcome.  The  history  of 
the  case  should  be  carefnlly  inquired  into ;  it  is  suggestive,  and  of  con- 
sequence in  sifting  the  puerperal  from  the  non-puerperal  origin. 

On  examination  a  smooth  pyriform  or  round  tumour  is  felt  in  the 
vagina,  or  protruding  through  the  cervix  ;  it  bleeds  readily  when  handled. 
The  cervical  ring  is  often  high  up,  and  the  fold  of  the  cervix  can  be 
felt  all  round ;  if  traction  by  a  fillet  or  noose  around  the  body  be  possi- 
ble the  fold  can  be  made  to  disappear  —  a  fact  of  some  importance  in 
differential  diagnosis  from  polypus.  The  depth  of  the  cervical  depres- 
sion depends  upon  the  extent  of  the  inversion,  but  the  continuity  can 
be  traced  round  the  base  without  any  sign  of  an  opening. 

In  the  dorsal  position,  with  two  fingers  in  the  rectum  and  the  opposing 
hand  placed  over  the  hypogastrium,  the  body  of  the  uterus  is  noted  to 
be  absent  from  the  normal  position,  and  the  fingers  of  the  hands  can  be 
made  to  meet.  The  two  forefingers  of  opposite  hands  in  the  vagina  and 
rectum  respectively  may  also  be  made  to  approach  each  other  over  the 
inversion.  The  recognition  of  the  peritoneal  orifice  of  the  inversion  is 
of  much  importance  when  it  can  be  felt  through  the  rectum  or  through 
the  abdominal  wall. 

A  sound  passed  into  the  bladder,  with  the  concavity  turned  back- 
Avards,  can  readily  be  met  by  a  finger  in  the  rectum  above  the  inverted 
uterus.  If  the  inversion  can  be  brought  to  view  by  a  speculum,  or  by 
sufficient  traction,  the  colour  may  be  seen,  and  possibly  the  openings  of 
the  Fallopian  tubes  made  out. 

The  sensibility  of  the  inverted  uterus  to  puncture  or  pressure  is  not 
always  a  trustworthy  sign ;  nor  is  its  absence  by  any  means  pathogno- 
monic. As  pointed  out  by  Newnham,  on  the  one  hand,  the  sensibility 
of  the  uterus  may  be  diminished  in  the  chronic  stage  of  inversion ;  and 
on  the  other  it  may  be  increased  in  polypus  by  inflammatory  action. 
Again,  if  a  polypus  be  covered  by  a  layer  of  uterine  tissue  the  distinc- 
tion, whether  with  regard  to  colour  or  sensibility,  is  less  appreciable. 

Differential  Diagnosis.  —  When  a  polypoid  tumour  is  present  in  the 
vagina  its  attachment  can  generally  be  reached,  and  a  sound  can  be 
passed  through  the  cervical  opening  into  the  uterus  for  some  inches. 
Adhesion  round  the  base  rarely  precludes  this  use  of  the  sound.  Bimanu- 
ally,  or  by  recto-abdominal  touch,  the  body  of  the  uterus  can  be  defined 
in  its  usual  position,  or  sometimes  retroverted.  It  is  between  partial  and 
chronic  inversion  and  polypus  that  great  difficulty  in  forming  accurate 
conclusions  is  sometimes  found.  Velpeau,  quoted  by  Simpson,  says 
that  there  are  cases  in  which  doubt  is  the  only  rational  opinion. 

Numbers  of  cases  are  recorded,  in  the  practice  of  experienced  men, 
in  which  the  inverted  uterus,  or  one  horn  of  the  inverted  uterus,  has 
been  operated  upon  by  ligature  or  otherwise,  for  supposed  polypus ; 
and,  conversely,  in  which  polypoid  tumours  have  been  removed  under 
the  impression  that  the  operator  was  dealing  with  an  inverted  uterus. 
With  the  progress  of  scientific  knowledge  and  im])roved  methods  of 
exploration  siicli  mistakes  ought  to  be  f(!W  and  far  between. 


CHRONIC  INVERSION  OF  THE    UTERUS  917 

The  past  history  of  the  case,  as  I  have  said,  is  signiticant.  In  a 
case  of  polypus  the  distance  the  nterine  sound  can  be  made  to  pass  is 
a  trustworthy  criterion. 

The  presence  of  the  uterus  in  its  normal  position,  and  the  absence  of 
any  trace  of  depression  on  bimanual  examination,  are  the  most  valuable 
signs.  If  the  tumour  be  sufficiently  low  for  traction  to  be  made  upon  it, 
the  remnant  of  the  cervical  canal  can  be  made  to  disappear  in  inversion  ; 
while  in  ])olypus  the  whole  uterus  with  the  attached  tumour  can  be  made 
to  descend  by  the  same  means.     The  coexistence  of  the  two  conditions 

—  polypus  with  partial  inversion  at  the  site  of  attachment  to  the  uterus 

—  presents  still  more  treacherous  ground  for  differential  diagnosis. 
Here  we  must  rely  mainly  upon  the  onset  and  progress  of  the  symptoms, 
together  with  a  thorough  bimanual  investigation. 

The  use  of  the  uterine  sound  renders  no  aid  in  this  instance  ;  but 
possibly  the  depression  or  dimpling  of  the  uterus  may  be  felt  by  the 
combined  use  of  the  hands. 

It  would  be  justifiable  in  such  cases  to  dilate  the  uterus  and,  imder 
an  anaesthetic,  to  examine  the  internal  and  external  surfaces  more  ex- 
actly. The  risk  of  such  a  proceeding  would  be  Avarranted  in  the  face  of 
a  greater  evil,  that  of  operative  interference  without  precise  knowledge 
of  the  actual  conditions. 

From  prolapse  of  the  uterus  the  diagnosis  should  be  easily  effected. 
The  procident  mass  is  wider  above  than  below;  at  the  lower  end  the 
orifice  of  the  os  uteri  can  be  seen,  and  a  sound  passed  into  it.  These 
facts  will  suffice  for  the  purpose.  Moreover,  the  sound  passed  through 
the  urethra  goes  downward  in  prolapse,  upward  in  inversion.  Manipula- 
tion detects  the  body  of  the  uterus  and  the  elongated  cervix,  which  in 
prolapse  are  readily  movable ;  while  examination  by  the  rectum  and 
recto-abdominally  shows  clearly  the  relative  position  of  the  parts.  In 
old  standing  cases  inversion  is  often  attended  with  some  degree  of 
prolapse  ;  when  the  descent  is  marked  the  vagina  is  involved  and  may  be 
inverted  also.     In  this  event  bladder  troubles  are  considerably  increased. 

Course  and  Results. — In  some  rare  instances  there  has  been  tolera- 
tion of  the  malady  for  many  years,  after  involution  has  taken  place ; 
and  more  particularly  when  the  menopause  has  been  passed. 

Occasionally,  as  before  stated,  inversion  has  been  present  without  the 
knowledge  of  the  patient,  though  as  a  rule  there  is  continuous  suffering. 
In  some  very  uncommon  instances  spontaneous  reinversion  takes  place. 
Dr.  Thomas  collected  twelve  cases;  another  is  reported  liy  Kenuirski; 
an  additional  one  happened,  under  the  care  of  Schultze,  after  the  removal 
of  a  myoma  from  the  fundus.  In  this  case  the  reinversion  began  at  the 
cervix  and  was  fully  effected  in  about  ten  days. 

The  usual  course  is  one  of  discomfort,  irregular  lupmorrhage.  septic 
symptoms,  attacks  of  pelvic  inflammation,  and  exhaustion  and  wasting 
of  general  strength,  until  reduction  brings  relief,  or  death  sujiervenes. 
The  general  mortality  is  estimated  by  Crampton  at  20  per  cent.  Thus 
32  out  of  120  recent  cases  died.     Of  104  chronic  cases  7  died. 


9i8  SYSTEM   OF  GYNECOLOGY 

Dr.  Busey  attributes  a  sliare  of  the  mortality  to  incompetence 
and  errors.  He  lays  stress  upon  the  disastrous  results  which  have 
arisen  from  mistakes  in  diagnosis  and  treatment,  and  denounces  the 
inexcusable'  blmiders  which  have  occurred  even  in  cases  under  the  care 
of  the  most  renowned  physicians  in  the  profession. 

However  deplorable  this  may  be,  it  must  be  remembered  that  advance 
in  surgical  art  is  largely  experimental.  The  faults  of  one  generation  are 
the  foundation  of  success  in  those  which  follow.  There  is  no  finality 
in  knowledge ;  no  monopoly  in  intelligence.  The  great  surgeon  Lisfranc, 
in  speaking  of  this  subject,  observed  that  "when  the  polypus  or  inversion 
has  only  partially  opened  the  os  uteri  we  are.  assured  that  the  diagnosis 
is  impossible  —  authors  do  not  even  consider  the  case."  From  this 
aspect,  surely,  progress  has  been  made,  and  though  infallibility  has  not 
been  reached  knowledge  has  been  gained.  Light  has  shone  through 
darkness.     Humanum  est  errare. 

Treatment.  — The  difficulties  of  reduction  in  chronic  inversion  of  the 
uterus  are  exemplified  by  the  infinite  variety  of  methods  employed  or 
recommended  by  various  authors.  Their  name  is  legion,  for  they  are 
many.  It  must  be  granted  that  there  is  no  one  plan  universally 
applicable.  Every  case  must  be  treated  upon  its  individual  merits. 
Unsuccessful  attempts  by  one  method  may  be  rewarded  by  success  in 
another,  or  by  a  combination  of  methods. 

The  chief  obstacles  to  reduction  are  the  rigidity  of  the  cervical  ring, 
with,  in  recent  cases,  increase  in  the  volume  of  the  uterus ;  or  in  long- 
standing cases  diminished  size  with  firmness  of  the  organ.  Another 
difficulty  is  found  in  the  mobility  of  the  uterus  and  in  the  difficulty  of 
obtaining  adequate  counter  pressure  to  the  force  applied  from  below. 

Peritoneal  adhesions  are  not  frequently  met  with ;  they  are  more 
often  surmised  than  found.  Experience  shows  that  even  when  desired 
for  the  closing  of  the  inner  opening  they  are  hard  to  produce  artificially. 

In  the  commonest  form  of  inversion,  as  pointed  out  by  Schultze, 
there  are  two  rings  of  the  uterine  wall  one  within  the  other.  If  the 
reduction  is  begun  by  seeking  first  to  press  the  fundus  upward  by 
indentation  a  third  ring  is  produced,  which  obviously  increases  the 
difficulty,  unless  the  cervical  constriction  be  already  dilated  or  dilatable. 
The  proper  method  is  to  grasp  the  inverted  body  and  to  press  it  uj)wards, 
so  that  the  cervix  may  be  dilated,  and  be  the  first  part  to  be  reduced : 
thus  we  imitate  the  method  l)y  which  spontaneous  rei aversion  takes  place. 

Ingenuity  has  been  shown  in  mechanical  contrivances,  skill  and 
dexterity  in  shrewd  adaptations,  and  exemplary  patience  in  manual 
efforts.  The  records  of  many  isolated  cases  have  contained  the  germs  of 
explanation  and  suggestive  reasoning.  From  the  special  to  the  general 
the  deduction  is  conclusive  that  steady,  sustained,  and  elastic  pressure  is 
the  treatment  likely  to  be  attended  with  the  greatest  amount  of  success 
and  good  ultimate  results.  There  is  apparently  no  limit  to  the  time 
when  it  may  be  employed  with  benefit;  in  cases  of  many  years'  duration 
it  is  still  applicable. 


CHRONIC  INVERSION  OF  THE    UTERUS  919 

The  principle  of  sustained  pressure  may  be  obtained  by  different 
means,  the  main  object  being  to  dilate  the  cervical  ring  and  to  restore 
first  that  part  last  inverted.  Sustained  pressure  may  be  solid  or  elastic ; 
with  the  hands,  with  instruments,  or  by  a  combination  of  elastic  bands 
with  appropriate  instruments. 

The  treatment  may  be  classified  as  follows :  — 

(i.)  Reposition  by  hands:  (a)  Aided  by  incision  (cervical,  uterine, 
abdominal).  (/>)  Aided  by  instruments,  (ii.)  Elastic  sustained  pressure : 
(iii.)  Amputation ;  vaginal  hysterectomy. 

Preliminary  Treatment. — In  all  cases  some  preparatory  treatment  is 
desirable.  The  patient  for  some  days  beforehand  should  be  kept  in  bed, 
the  diet  regulated,  and  the  bowels  well  moved.  Free  vaginal  injections 
of  hot  water,  followed  by  a  lotion  of  mercuric  perchloride  (1  in  2000) 
should  be  used  night  and  morning;  the  manipulating  hands  must  be 
thoroughly  cleansed. 

In  attempting  manual  reposition  the  patient  should  be  placed  in  the 
lithotomy  position  at  the  edge  of  a  level  table.  A  Clover's  crutch  is 
used,  and  an  ansesthetic  must  always  be  administered.  The  use  of  a 
Barnes'  bag  in  the  vagina  for  some  days  beforehand  may  make  more 
room  ;  and  in  some  instances  may  even  of  itself  effect  reposition  (Kroner). 
Gariel's  air  pessary  has  also  been  used  with  the  same  result. 

Emmet's  method  is  as  follows :  The  hand  is  placed  in  the  vagina, 
the  fingers  and  thumb  encircling  the  portion  of  the  body  close  to  the  seat 
of  inversion,  the  fundus  resting  in  the  palm  of  the  hand.  This  portion  of 
the  body  is  firmly  grasped  and  pushed  upwards,  and  the  fingers  are  then 
immediately  separated  to  the  utmost.  At  the  same  time  the  other  hand 
is  employed  over  the  abdomen  in  the  attempt  to  roll  out  the  parts  form- 
ing the  ring,  by  sliding  the  abdominal  parietes  over  its  edge.  As  the 
transverse  diameter  of  the  cervix  and  os  is  increased  by  the  outspread 
fingers  the  long  diameter  of  the  body  becomes  shortened.  In  one  of 
Emmet's  cases  reduction  was  completed  in  three  hours  and  fifty-five 
minutes.  In  another,  after  three  hours'  effort,  the  treatment  was  stopped 
for  the  time,  and  resumed  a  month  later.  Five  hours,  Avith  change  of 
operators,  was  spent  on  this  occasion  without  success ;  but  finally,  a  week 
after  the  latter  attempt,  the  inverted  uterus  was  completely  reduced  in 
twenty-seven  minutes  by  the  same  method. 

To  aid  fixation  the  uterus  was  drawn  down  to  the  vulva,  and  the 
edge  of  the  cervix  on  each  side  seized  with  tenaculums,  which  frequently 
tore  out.  xVran  recommended  jMuseux's  forceps  or  tenaculum  hooks  for 
this  purpose;  and  Freund  introduces  broad  silk  ligatures  at  several 
points  of  the  circumference,  and  thus  forcibly  drags  down  the  vaginal 
portion  while  pressing  the  body  upwards. 

Noeggerath  compresses  the  body  of  the  uterus,  opposite  to  each 
horn,  by  the  thumb  and  finger;  so  as  to  indent  it  on  one  side  or  the 
other.  Whon  this  can  be  effected  the  indented  horn  acts  as  a  wedge 
whi("li  facilitates  the  passage  of  the  remaining  ]iortion  of  the  body. 
Marion  Sims  succeeded  readily  in  pushing  in  this  part  of  the  uterine 


920  SYSTEM  OF  GYNECOLOGY 

wall  after  the  body  had  entered  the  cervical  ring  —  a  method  previously- 
advocated  by  Kiwisch.  It  is  stated  by  Dr.  Thomas  to  be  more  applicable 
and  possible  at  this  stage  of  the  process  than  at  the  beginning  of  the 
treatment. 

Conrty  insists  upon  the  necessity  of  keeping  the  cervix  fixed  with  two 
fingers  introduced  into  the  rectum.  The  cervix  is  drawn  down  outside 
the  vulva  and  held  with  Museux's  forceps  :  the  index  and  middle  fingers 
of  the  left  hand  are  introduced  into  the  rectum,  and  by  bending  them 
forward  the  cervix  is  easily  fixed  through  the  rectal  wall.  With  the 
right  hand  the  uterus  is  pushed  back  into  the  vagina ;  the  fundus,  con- 
tained in  the  palm  of  the  hand,  being  turned  towards  the  pubes.  With 
the  thumb  and  index  finger  of  the  right  hand  pressure  is  exercised  on  the 
pedicle  of  the  tumour,  so  as  gradually  to  increase  the  depth  of  the  utero- 
cervical  groove.  The  first  stage  is  accomplished  by  pushing  the  body 
of  the  uterus  upwards  as  stated,  while  the  neck  is  retained  through  the 
rectum ;  the  second  by  compressing  the  fundus  laterally,  and  by  pressing 
the  thumb  into  a  horn  of  the  uterus. 

Tate's  method  is  ingenious  ;  it  consists  in  fixing  and  dilating  the  neck 
by  inserting  two  fingers  of  the  right  hand  into  the  rectum,  and  the 
index  finger  of  the  left  hand  through  the  urethra,  while  pressure  is  made 
against  both  horns  by  the  thumbs. 

Many  other  plans  have  been  proposed  ;  some  original,  some  based 
upon  combination  of  known  methods. 

Watts  of  New  York  easily  effected  reduction  in  a  case  by  the 
following  plan :  "  The  uterus  is  drawn  down  to  the  vaginal  outlet,  two 
fingers  are  placed  in  the  rectum,  one  of  these  through  the  wall  into  the 
depression:  the  uterus  is  then  pushed  on  to  it  from  the  vagina,  the 
second  finger  is  then  added  to  the  first,  and  when  sufiicient  dilatation 
of  the  ring  is  ensured  the  uterus  can  be  returned." 

Barrier  (9a)  made  pressure  with  both  hands,  pressing  the  thumb 
against  the  fundus,  and  the  cervix  against  the  sacrum  for  counter 
pressure. 

Incision.  —  Sir  James  Simpson  (73a)  found  that  in  forcible  reposition 
the  edges  of  the  cervix  were  fissured  or  slit ;  he  therefore  suggested 
incision  as  an  aid.     Marion  Sims  also  proposed  the  same  method. 

Dr.  Barnes  (o}^.  cit.  p.  741),  writing  in  ISGO,  states  that  for  twenty  years 
he  had  taught  in  his  lectures  that  the  unyiekling  cervix  may  be  divided 
by  incisions  carried  into  its  substance  from  above  downwards,  at  different 
points  of  its  circumference ;  pressure  then  applied  will  cause  it  to  yield 
easily.  In  one  case  this  was  accomplished  successfully.  The  uterus  was 
drawn  down  by  a  sling  noose  of  tape,  and  three  incisions  were  made,  one 
on  each  side  and  one  posteriorly.  Still  he  recommends  the  use  of  this 
only  after  a  trial  of  Tyler  Smith's  plan,  and  then  with  great  caution. 
Subsefjucntly  lie  advises  that  two  incisions  only  should  be  made,  and 
that  rein  version  should  be  limited  to  elastic  pressure. 

Dr.  Matthews  Duncan  treated  one  case  by  incision  from  the  internal 
OS  to  the  middle  of  the  body  in  frcuit  and  behind,  followed  by  application 


CHRONIC  INVERSION   OF   THE    UTERUS  921 

of  taxis  for  reduction  —  a  plan  fraught  with  considerable  risk  from  hemor- 
rhage and  septic  infection. 

Other  cutting  operations  have  also  been  proposed  in  conjunction  ■with 
internal  dilatation.  Browne  describes  this  method  as  follows :  The 
inverted  fundus  is  drawn  outside  by  strong  volsella  forceps  until  the 
openings  of  the  Fallopian  tubes  are  seen.  An  incision  an  inch  and  a  half 
long  is  then  made  posteriorly ;  through  this  a  dilator  is  passed  up  into  the 
cervix,  and  expanded  until  the  tissues  are  felt  to  relax.  The  opening  is 
then  further  stretched  by  hard  rubber  dilators ;  the  incision  is  sutured, 
and  the  inversion  reduced  by  manipulation.  With  the  incision,  stretch- 
ing, and  handling,  it  would  seem  that  the  patient  is  exposed  to  risks 
which  make  the  operation  hazardous,  and  hardly  justifiable  with  the 
alternative  of  others  which  have  stood  the  test  of  experience. 

Somewhat  similar  is  the  practice  of  Kiistner,  which  he  thus  describes 
in  one  case:  Patient  set.  19,  primip.  Four  different  replacement  meth- 
ods and  colpeurysis  had  been  tried  without  success.  In  the  dorso-gluteal 
position  the  part  was  drawn  with  volsella  forceps  firmly  downwards, 
so  that  the  inverted  uterus  lay  in  the  vulva ;  Douglas'  pouch  Avas  opened 
wide,  and  the  index  finger  of  the  left  hand  was  inserted  into  the  inversion 
infundibulum.  As  the  latter  was  free  from  adhesions,  it  was  possible 
to  get  quite  to  the  bottom  of  it  and  to  bring  the  whole  uterus  easily  in 
front  of  the  vulva.  Further  reversion  attempts  were  carried  out  so 
that  through  Douglas'  pouch  with  the  index  and  middle  fingers  of  the 
left  hand  the  inversion  infundibulum  could  be  fixed,  and  with  the  thumb 
of  the  same  hand  Kiistner  tried  to  invaginate  the  fundus  uteri,  but  with- 
out success.  Leaving  the  index  finger  of  the  left  hand  in  the  infun- 
dibulum, he  cut  longitudinally  for  a  length  of  2  cm.  from  the  surface  of 
the  mucous  membrane  through  the  posterior  wall  of  the  uterus,  exactly 
in  the  median  line  in  the  region  of  the  inner  os  uteri.  Then  the  rever- 
sion method  previously  employed  Avas  repeated,  and  success  easily  fol- 
lowed. The  reverted  uterus  was  firmly  retroflexed ;  a  longitudinal  wound 
in  the  posterior  wall  of  the  uterus  was  drawn  Avith  a  volsella  forceps 
into  the  wound  of  Douglas'  pouch,  and  the  former  sutured  peritoneally 
by  three  deep  and  two  superficial  sutures ;  thereupon  the  Avound  in 
Douglas'  pouch  Avas  also  attached  Avith  fi\'e  sutures  to  the  posterior  vagi- 
nal wall  Avith  the  result  of  recovery  Avithout  febrile  reaction. 

Incision  through  the  Abdomen.  —  In  1869  Dr.  Gaillard  Thomas  re- 
ported a  case  in  Avhich  he  carried  out  a  novel  plan  and  achieved  a  great 
success.  The  patient,  tAvent3r-three  years  old,  had  borne  one  child  tAventy- 
one  months  before.  Fourteen  determined  and  prolonged  attempts  by 
experienced  and  able  men  had  failed  to  reduce  the  inversion.  On  the 
last  of  these  attempts  Dr.  Thomas  incised  the  site  of  the  stricture,  when 
a  nearly  fatal  haemorrhage  folloAved.  A  Aveek  later  the  abdomen  Avas 
opened  in  the  median  line,  and  the  internal  ring  Avas  dilated  by  specially 
made  forceps.  A  rent  Avas  made  in  the  anterior  vaginal  Avail  b}'  the  force 
used  from  below.  The  operation  xmder  ether  lasted  one  hour,  the  actual 
replacement  occupying  tAventy-seven  minutes.     The  patient  made  a  good 


922  SYSTEM  OF  GYNECOLOGY 


recovery.  In  a  similar  case  under  his  care  the  replacement  was  easily 
effected,  but  the  patieut  died  from  peritonitis  forty-eight  hours  after- 
wards. This  plan  has  been  tried  by  others  with  indifferent  success. 
The  principle,  however,  is  a  rational  one ;  and  it  is  offered  as  a  substitute 
for  amputation  of  the  uterus  after  all  other  means  have  been  fairly  tried. 
As  such  it  must  be  regarded  as  a  valuable  contribution  to  the  methods 
of  treatment  at  our  disposal ;  it  is  certainly  not  more  difficult,  and  it  is 
less  dangerous  than  amputation. 

In  1S85  I  published  a  case  in  which  reduction  was  attempted  on 
somewhat  similar  lines.  After  renewed  efforts  by  taxis  and  pressure 
the  abdomen  was  opened  and  the  constricted  ring  dilated  by  bone  glove 
stretchers.  A  thread  of  whipcord  was  then  passed  from  above  through 
the  fundus,  and  a  button  was  attached  to  the  distal  end.  Continued 
upward  traction  for  nearly  an  hour  failed  to  make  any  impression  towards 
replacement.  Two  weeks  later  the  condition  of  the  uterus  induced  me 
to  remove  it  through  the  vagina  by  elastic  ligature.  The  patient  made 
a  rapid  recovery. 

The  Hand  and  Instruments.  —  Dr.  Thomas  used  as  a  substitute  for 
the  hand  a  conical  plug  of  box- wood  four  inches  long  for  making  counter 
pressure  over  the  abdomen.  The  cone  was  inserted  into  the  abdominal 
ring  of  the  uterus,  and  it  was  gradually  forced  down  into  the  inverted 
fundus  for  such  a  distance  as  to  dilate  the  cervix  and  allow  reposition. 
A  rectal  bougie  has  been  used  for  the  same  purpose,  or  a  cone  eight 
inches  long  and  one  inch  diameter,  or  forceps  wrapped  with  gauze. 

Elastic  sustained  Pressure.  —  Sustained  pressure  has  been  obtained 
in  a  variety  of  ways.  Dr.  Tyler  Smith  in  1858  made  an  important  ad- 
vance upon  the  former  methods  of  treatment  by  the  use  of  elastic  press- 
ure. He  succeeded  by  placing  a  Gariel's  air  pessary  into  the  vagina, 
upon  which  external  pressure  was  exercised  by  a  T-bandage  and  a  gradu- 
ated compress  placed  at  the  vulva.  By  this  means  slow  and  gradual 
dilatation  of  the  os  is  produced,  with  softening  of  the  cervical  ring  ;  and 
opportunity  is  thus  given  for  the  inverted  uterus  to  recover  itself,  or 
assistance  may  be  given  by  the  hand.  Dr.  Thomas  modified  this  plan  by 
packing  round  the  inverted  uterus  with  tampons  of  carbolised  cotton 
soaked  in  glycerine ;  then  he  introduced  an  india-rubber  bag  filled  with 
water,  and  retained  it  in  position  by  a  broad  strip  of  plaster  passing  be- 
tween the  thighs  from  the  lumbar  region  behind  to  the  umbilicus  in  front. 
Pressure  is  regulated  ]jy  injecting  more  water,  or  letting  some  out  by 
means  of  a  stop-cock.  As  already  noted,  the  same  principle  has  been 
adopted  in  a  more  manageable  form  by  the  use  of  P>arnes'  bags  filled 
with  air.  "  A  bag  consisting  of  a  double-walled  india-rul)ber  capsule 
which  is  slipped  over  the  iiterus  has  been  devised  by  Thiry.  When 
distended  with  air  it  ])resses  and  pushes  up  the  inverted  fundus." 

Dr.  AVliite  of  Buffalo  was  one  of  the  earliest  surgeons  to  direct  atten- 
tion to  the  benefit  of  sustained  pressure.  In  his  plan  ])ressure  is  made  by 
a  spiral  spring,  one  end  of  which  is  placed  againstthel)reast  of  tlie  operator. 
The  spring  is  prolonged  into  a  curved  stem  of  wood  or  rubber,  at  the  end 


CHRONIC  INVERSION  OF  THE    UTERUS 


923 


of  which  is  a  disc  tipped  with  soft  rubber.  One  hand  is  introduced  into 
the  vagina  to  grasp  the  uterus  and  keep  the  cup  in  position,  while  the  free 
hand  is  employed  over  the  pubes  to  make  counter  pressure,  and  assist  in 
expanding  the  inner  depression  of  the  inversion.  The  spring  requires  a 
pressure  of  eight  to  ten  pounds  to  bring  it  down.  With  the  patient  in 
the  dorsal  position  at  the  end  of  the  table,  and  under  an  anaesthetic, 
this  method  is  capable  of  producing  effective  results,  tedious  and  weari- 
some though  it  be. 

Elastic  Pressure. — This  is  by  far  the  most  efficient  method  yet  known. 
The  cardinal  points  are  that  it  should  be  gentle,  elastic,  and  sustained  in 


Fig.  242. 


the  direction  of  the  pelvic  axes.  It  must  be  repeated  again  and  again,  if 
necessary,  and  kept  up  persistently  and  perseveringly  with  vigilant  care. 
With  this  method  in  view  previous  prolonged  handling,  squeezing, 
and  pressure  by  taxis,  is  unwarrantable.  It  is  wiser  and  safer  to  begin 
with  it  at  once  after  preliminary  antiseptic  irrigation.  Aveling's  repositor 
is  the  best  means  of  producing  the  pressure.  This  consists  of  a  stem 
with  a  double  curve  —  perineal  and  pelvic — surmounted  b}-  a  cup  which  is 
placed  against  the  fundus.  The  pressure  is  exerted  by  four  elastic  rings 
fastened  by  bands  to  a  waist  bolt,  which  in  its  turn  is  supported  by 
shoulder-straps.  By  the  adaptation  of  these  the  degree  and  the  direction 
of  the  pressure  can  be  very  fairly  regulated.     Cups  of  different  size  are 


924  SYSTEM   OF  GYNECOLOGY 

made  to  fit  the  stem.  When  the  inversion  is  reduced  the  cup  is  some- 
times retained  within  the  uterus,  and  is  not  easily  extracted.  In  one 
case  r  had  considerable  difficulty  in  getting  it  out. 

In  a  case  happening  under  Scanzoni's  (69)  notice  the  button  end  of  a 
stem  was  retained  under  similar  circumstances.  The  advice  he  gave 
might  be  followed  ;  that  as  the  stem  had  entered  by  firm  and  persistent 
pressure  it  should  be  removed  by  the  same  means.  An  elastic  band  was 
attached  from  the  end  of  the  stem  to  the  bedpost,  and  it  was  thus  gradu- 
ally withdrawn. 

Dr.  Galabin  obviates  this  danger  by  making  the  cup  form  the 
summit  of  a  cylinder  If  inches  long.  Thus  the  cervix  is  prevented  from 
closing  up  after  reduction,  when  the  instrument  is  readily  removed. 
Careful  watching  is  necessary  when  the  instrument  is  in  place ;  the  bands 
may  require  tightening  at  intervals,  and,  if  there  be  much  pain,  opiates 
must  be  given.  Restoration  is  generally  effected  by  this  plan  within 
forty  hours.  In  my  own  case  three  days  elapsed  before  the  reduction  was 
complete,  but  it  was  necessary  to  suspend  it  for  some  hours  on  account 
of  the  pain  produced.  Aveling  states  that  a  pressure  of  21-  pounds  is 
sufficient  to  effect  reduction.  He  reports  eleven  cases  successfully  treated 
by  this  method,  and  goes  so  far  as  to  say  that  every  case  of  inversion  can 
be  cured  by  reposition.  However,  he  subsequently  recorded  one  where 
it  did  not  succeed. 

When  known  methods  have  failed  after  repeated  attempts,  or  where 
firm  adhesions  exist,  the  inversion  may  become  irreducible.  Under  these 
circumstances  Emmet  proposes,  •'  where  the  fundus  can  be  gotten 
within  the  cervix,"  to  bring  the  edges  of  the  cervix  together  by  silver 
sutures  for  a  time,  until  additional  efforts  at  reduction  can  be  made. 
Failing  this  he  denudes  the  edges  of  the  cervix,  and  unites  them  per- 
manently, leaving  a  small  space  open  at  each  end. 

He  regards  this  plan  as  far  preferable  to  abdominal  incision  or  to 
amputation.  Indeed,  he  looks  upon  the  mortality  of  amputation  as  so 
great  that  he  would  not  resort  to  the  operation  under  any  circumstances. 

Amputation.  —  The  mortality  of  this  operation  is  as  high  as  30  per 
cent.  It  should  only  be  practised  as  a  last  resort.  Indeed,  in  the  light 
of  present  knowledge  the  instances  in  which  it  is  admissible  must  be 
excessively  rare.  When  in  the  wide  field  of  treatment  the  relative 
infrequency  of  irreducible  cases  is  remembered,  the  chances  of  being 
urged  to  amputation  must  be  very  remote.  The  chief  dangers  of  ampu- 
tation are  haemorrhage,  retraction  of  the  stump  within  the  peritoneal 
cavity,  and  septicaemia.  Amputation  by  the  knife,  with  certain  pre- 
cautions, is  the  most  direct  method.  The  uterus  is  drawn  down  and  a 
temporary  elastic  ligature  placed  around  the  neck ;  three  or  four  wire 
sutures  are  tlien  passed  througli  the  cervix  from  before  backwards,  and 
the  uterus  amputated  half  an  inch  below  these.  Bleeding  points  are 
ligatured,  and  the  sutures  are  ])ronght  firmly  togfithcr  over  the  stump. 
Superficial  sutures  are  placed  to  unite  the  mucous  m(!ml)rane,  and  the 
elastic  ligature  is  now  removed ;  or  a  ligature  may  be  passed  through 


CHRONIC  hW VERSION   OF   THE    UTERUS  925 

the  neck  and  tied  laterally  so  as  to  control  the  uterine  vessels,  the  uterus 
being  removed  below  this. 

Vaginal  hysterectomy  is  another  method  of  removing  the  uterus. 
The  broad  ligaments  are  tied  or  clamped  with  forceps  on  both  sides,  when 
the  uterus  can  be  rapidly  removed  by  scissors.  The  vaginal  space  is 
packed  with  iodoform  gauze.  Rigid  antiseptic  precautions  place  these 
operations  on  a  more  secure  footing,  and  greatly  enhance  the  prospects 
of  recovery. 

The  elastic  ligature  still  finds  much  favour  in  France.  It  is  described 
by  Courty  as  presenting  more  advantages  and  fewer  dangers  than  any 
other  plan  of  extirpation.  He  advises  that  before  applying  it  a  groove 
should  be  made  round  the  pedicle  of  the  tumour  by  the  actual  cautery. 
Elastic  tubing  is  used,  and  it  is  tightened  daily  until  the  tumour  falls 
off,  which  is  generally  about  the  twelfth  to  the  eighteenth  day. 

The  ecraseur  has  been  used  with  good  results  in  the  hands  of  some 
surgeons,  and  the  galvano-cautery  has  been  successful  in  the  practice  of 
Spiegelberg.  The  use  of  both  is  destined  to  aid  the  progress  of  art 
towards  more  efficient  and  safer  measures  based  upon  sounder  principles. 

Edward  Malixs. 

REFERENCES 

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iv.  533. —21.  Davies.  "  Clironic  Invcrsidu  of  the  Uterus."  B.  M.  J.  Loud.  1885,  ii. 
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926  SYSTEM   OF  GYNECOLOGY 

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I'nterus  (inversion  supero-laterale),  amputee  par  I'ecraseur-line'aire,  avec  suture,"  Bull. 
Acad,  roijale  ine'd.  de  Beige,  Brux.  1887,  iv.  s.  1,  723. — 29.  Fox.  "A  unique  and 
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"  Zwei  weitere  Falle  von  Inversion  der  Gebarniutter,"  Frauenarzt,  Berl.  1887,  ii.  373.  — 
33.  Hermax.  "  Iu%-erted  Uterus,"  2V.  O.  S.  188(J,  xxvi.  83. — 31.  Hektoghe.  "Ampu- 
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Uterus,  treated  after  ^ying's  method,"  Am.  J.  Obst.  N.  Y.  1884,  xvii.  815. —  39.  Kara- 
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der  chronischen  totalen  Uterus-inversion,"  Centralhl.f.  Gyndk.  Leipz.  1890,  xiv.  658. — 
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DISEASES   OF  THE  FEMALE  BLADDER  AND    URETHRA       927 

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80.  Weissenberg.  "  Inversio  Uteri  nach  Abort;  rasche  und  spontane  Reduktion  durch 
Tamponade," /"rau^war^z,  Berl.  1889,  vi.  8.  —  81.  Werth.  "  Ueber  partielle  Inversion 
des  Uterus  durch  Geschwiilste,"  Arch.  f.  Gj/ncik.  Berl.  1893,  xxii.  (Jo. — 82.  "Chronic 
Inversion  of  Uterus  of  Twenty-one  Months'  Duration  reduced  by  Colpenrysis,"  J. 
Am.  M.  Ass.  Chica(/o,  1887,  viii.  22;  dis3.  44. — 83.  "Spontaneous  Reduction  of  a 
chronically  inverted  and  completely  prolapsed  Uterus,"  Boston  Med.  and  Surg.  Jour. 
1892,  cxxvii.  39. — 84.  "  Ein  Fall  von  totaler  Inversio  Uteri  in  Folge ;  spontaner 
Geburt  eines  fibrosen  Polypen  ;  Heilung,'  Memorabilien.  Heilbr.  1894,  u.  F.  iv.  217. — 
85.  "  Inversion  totale  de  I'ute'rus  de  cause  ditttcile  a  de'terminer,"  Gaz.  med.  de  Nantes, 
1884-5,  iii.  117. — 86.  "Inversion  uterine  irre'ductible ;  amputation  de  I'ute'rus  par  la 
ligature  avec  tractions  e'lastiques;  gue'rison,"  Lyon  mid.  1886,  li.  441,  Disc.  455. — 
87.  "Note  sur  I'inversion  ute'riue  et  sou  traitement,"  Arch,  de  med.  et  de  ehir.  prat. 
Brux.  1887-8,  il.  113. 

E.  M. 


DISEASES   OF   THE  FEMALE   BLADDER  AND   URETHRA 

MoKBiD  conditions  of  the  lower  urinary  organs  in  the  female,  as  in  the 
male,  chiefly  show  themselves  in  pain  and  frequency  in  micturition. 
In  a  large  number  of  these  cases  the  manifestations  depend  upon  the 
presence  of  cystitis  in  a  more  or  less  severe  degree ;  and  it  is  a  point  of 
first  importance  to  determine  whether  cystitis  be  present,  or  onl}-  some 
condition  resembling  it  in  its  more  prominent  features  of  pain  and  fre- 
quency of  micturition  and  the  presence  of  pus  and  blood  in  the  urine : 
it  is  important,  in  the  next  place,  if  it  be  cystitis,  to  determine  on  what 
local  or  remote  cause  it  depends. 

Diseases  of  the  Urethra. — The  morbid  conditions  met  with  in 
the  female  urethra  are  but  few. 

Developmental  defects :  these  are,  (i.)  Entire  absence  of  urethra ; 
(ii.)  Hypospadias ;  (iii.)  Deficiency  of  internal  portion ;  (iv.)  Atresia  of 
the  urethra  (congenital). 

Displacement :  this  occurs  chiefly  as  longitudinal  traction  by  dis- 
placement ujjwards  of  the  bladder;  it  causes  frequency  of  micturition. 

Neoplasms  :  such  as  papilloma  and  polypi  of  the  mucous  membrane; 
they  may  cause  some  obstruction  without  much  local  tenderness;  in  rare 


928  SYSTEM   OF  GYNECOLOGY 

instances  sarcoma  and  carcinoma  are  met  with,  but  the  most  common 
neoplasm  is  the  vascrdar  groictli  or  urethral  caruncle.  The  urethral  caruncle 
consists  of  dilated  capillaries  in  connective  tissue  covered  with  squamous 
epithelium',  which  form  a  small  bright  red  tender  and  vascular  tumour  at 
the  urethral  orifice.  The  symptoms  are  pains  on  micturition  or  coitus, 
sometimes  retention  of  urine.  The  most  effective  mode  of  treatment  is  to 
destroy  the  prominence  with  the  actual  cautery,  care  being  taken  to  arrest 
any  bleeding  afterAvards  by  plugging  and  pressure  with  a  perineal  band. 

Cysts  and  Abscesses.  —  Cysts  containing  clear  mucoid  fluid  or  pus  are 
occasionally  met  with  in  the  urethro- vaginal  septum ;  they  are  due  to 
dilatation  and  inflammation  of  Skene's  glands  which  are  situated  near 
the  mouth  of  the  urethra.  Bartholin's  glands  (corresponding  to  Cowper's 
glands  in  the  male)  are  sometimes  the  seat  of  inflammation,  suppuration, 
or  neoplasms.  Enlarged  acinous  mucous  glands  are  sometimes  found 
near  the  external  urethral  orifice. 

Urethritis  is  usually  associated  with  gonorrhcBa.  The  urethra  is 
swollen  and  tender,  and  yields  pus  when  pressed  upon  through  the 
anterior  vaginal  wall.  The  most  effective  treatment  is  to  give  diluent 
drinks  and  copaiba,  to  use  iodoform  bougies  locally,  and  counter  irrita- 
tion, by  painting  the  anterior  wall  of  the  vagina  with  tincture  of  iodine. 

Dilatation  sometimes  occurs  as  a  result  of  coitus  when  the  vagina  is 
occluded  or  over-distended.  This  very  rare  condition  is  to  be  remedied 
by  burning  a  longitudinal  furrow  by  the  actual  cautery  with  the  aid  of 
a  grooved  specrxlum. 

Tubercular  disease  sometimes  begins  in  the  female  urethra,  and  when 
present  frequently  causes  pain  or  incontinence  of  urine,  hsematuria  or 
pyuria. 

Diseases  of  the  Bladder.  —  The  congenital  defects  of  the  bladder 
are  malposition,  supernumerary  bladders,  absence,  and  ecstrophy. 

The  bladder  may  be  protruded  in  a  hernial  form  when  the  linea  alba 
is  weak  or  deficient,  or  when  the  expansion  of  the  oblique  muscles  of 
the  abdomen  is  absent. 

If  the  whole  of  the  front  wall  of  the  abdomen  is  deficient  in  the 
hypogastrium,  and  the  bladder  properly  developed,  the  bladder  will 
protrude  at  the  opening.     This  is  not  the  same  thing  as  ecstrophy. 

In  most  of  the  cases  of  protrusion  or  displacement  of  the  bladder 
the  condition  is  not  congenital  but  acquired. 

Displacement.  —  Owing  to  its  loose  attachment  to  the  wall  of  the 
pelvis  the  bladder  in  the  woman  is  readily  displaced.  It  is  drawn  up 
during  labour,  and  by  retroversion  of  the  enlarged  uterus,  whether  this 
be  due  to  gestation  or  fibromyoma ;  or  it  may  be  attached  to  an  ovarian 
or  fibroid  tumour  which  has  risen  into  the  abdomen.  In  procidentia 
uteri,  the  commonest  cause  of  cystocele,  a  part  of  the  bladder  is  dis- 
Y>laced  downwards,  and  this  may  lie  outside  the  vagina.  In  contraction 
of  the  sacro-uterine  ligaments  the  bladder  is  drawn  backwards  and  held 
l)artly  open,  so  that  it  is  never  completely  emptied. 


DISEASES    OF   THE   FEMALE   BLADDER   AND    URETHRA       929 

Great  protrusions  are  sometimes  met  with  in  the  middle  Hue  at  the 
scar  of  a  laparotomy  wound,  or  of  an  abscess.  Over-distension  of  the 
abdominal  walls  from  any  cause,  followed  by  emaciation  or  the  fiaccid- 
ity  of  age,  is  a  sequence  which  lends  itself  to  hernial  protrusion  of  the 
bladder  as  of  other  viscera.  The  inguinal,  femoral,  obturator,  and  ischi- 
atic  foramens  have  all  been  the  site  of  cystocele,  sometimes  accompanied 
by  protrusion  of  a  portion  of  bowel  or  omentum.  Vaginal  cystocele  is 
by  no  means  uncommon  in  fat  and  flabby  multiparas. 

The  protruding  part  of  the  bladder  is  uncovered  by  peritoneum  ex- 
cept when  accompanied  or  preceded  by  an  ordinary  hernia  of  large  size, 
or  when  a  great  portion  of  the  bladder  is  included  in  it. 

Besides  the  weakened  condition  of  the  abdominal  walls  or  vagina,  or 
the  easy  patency  of  one  of  the  natural  openings  in  the  parietes,  two  other 
conditions  are  requisite  for  cystocele :  these  are  a  dilated  bladder,  frequent 
and  considerable  distension,  and  frequent  straining  efforts  at  micturition. 
As  soon  as  the  bladder  has  escaped  at  a  hernial  protrusion  it  acquires  a 
more  or  less  sacculated  or  hour-glass  form ;  and  the  urine,  being  con- 
stantly retained,  at  length  decomposes,  and  ulceration,  calculus  forma- 
tion, or  sloughing  may  follow. 

Cystocele  has  been  mistaken  for  ordinary  hernia,  and  for  abscess.  It 
varies  in  size  with  the  quantity  of  urine  retained,  and  may  be  distended 
by  injecting  the  bladder  with  warm  boracic  fluid.  In  doubtful  cases 
Agnew  recommends  puncture  and  an  examination  of  the  fluid  withdrawn ; 
but  this  procedure  has  its  dangers. 

If  a  cystocele  become  strangulated  the  symptoms  may  ver}^  closely 
simulate  a  strangulated  hernia;  but,  in  addition,  there  will  almost  cer- 
tainly be  other  symptoms  special  to  the  bladder,  such  as  blood  in  the 
urine,  painful  and  frequent  micturition,  and  pain  specially  referred  to 
the  hypogastrium  and  neck  of  the  bladder. 

Petit  says  that  in  straiigulated  hernia  of  the  bladder  vomiting  is 
always  preceded  by  hiccough,  whereas  in  hernia  of  the  intestine  vomit- 
ing precedes  hiccough. 

Treatment.  —  The  pouch  of  bladder  should  be  kei>t  empty  of  urine  by 
voluntary  micturition  or  the  catheter,  and  by  the  application  of  a  truss. 

A  vaginal  cystocele  should  be  treated  by  an  operation  for  contracting 
the  anterior  vaginal  wall.  Most  of  the  cases  which  have  been  recorded 
as  supernumerary  bladdershave  been  either  sacculated bladdersor  bladders 
bisected  by  a  membranous  partition.  In  some  the  coats  have  been  com- 
plete, and  others  were  probably  dilated  lower  extremities  of  the  ureters. 
In  some  of  the  cases  in  Avhieh  the  bladder  was  divided  into  two,  there 
was  an  opening  of  communication  between  them,  in  others  not ;  one 
ureter  opens  into  each  division.  Fantoni  and  ]\[ollinetti  have  described 
cases  of  true  multiple  bladders ;  that  of  the  latter  was  a  woman  Avho  had 
five  bladders,  five  kidneys,  and  six  ureters.  Four  of  the  ureters  emptied 
each  into  a  sejjarate  bladder ;  the  other  two  into  the  largest  bladder. 

Prolapse  of  the  bladder  mucous  membrane  through  the  urethro-vesical 

3  o 


930  SYSTEM   OF  GYNAECOLOGY 

orifice  is  less  imcommon  in  women  than  in  men ;  it  sliould  be  treated  by 
applying  the  actual  cautery  to  the  vesical  orifice  while  the  wall  of  the 
bladder  is  kept  in  place  by  a  catheter. 

Only  a  few  instances  of  absence  of  the  bladder  are  on  record.  When 
it  occurs  the  ureters  open  into  the  urethra,  rectum,  or  vagina;  or  on 
the  abdomen,  generally  in  the  median  line.  Agnew  quotes  a  few  cases 
in  which  individuals  so  affected  lived  to  adult  age,  suffering  little  or  no 
inconvenience  ;  others  survived  but  a  few  days. 

Ectopion  vesicae  is  characterised  by  a  failure  in  development  of  the 
anterior  wall  of  the  bladder  and  of  the  abdominal  wall  in  front  of  the 
bladder;  whilst  the  posterior  wall  of  the  bladder  projects  at  the  hypo- 
gastrium  Avhere  it  is  continuous  with  the  anterior  abdominal  parietes. 

This  malformation  is  more  frequent  in  boys  than  in  girls,  in  the 
proportion  of  eight  or  nine  to  one. 

In  its  causation  the  theory  of  arrest  of  development  is  generally 
accepted.  The  existence  of  epispadias,  the  absence  or  non-union  of  the 
symphysis  pubis,  and  other  associated  malformations  of  the  genital 
organs,  are  arguments  in  favour  of  this  opinion. 

Morbid  Anatomy.  —  Ectopion  vesicae  appears  as  a  florid  red  body  in 
the  hypogastric,  or  hypogastric  and  pubic  regions.  In  very  young  sub- 
jects it  is  not  larger  than  a  nvit ;  in  adults  it  attains  the  size  of  an  apple. 

The  surface  bleeds  readily,  and  is  often  painful ;  the  lower  part  is 
always  moister  and  more  vascular  than  the  upper ;  and  upon  it  there  are 
two  small  round  projections,  which  represent  the  orifices  of  the  ureters  : 
on  watching  these  urine  is  seen  to  flow  from  them  —  not  drop  by  drop 
but  by  a  sort  of  feeble  and  irregular  ejaculation. 

At  the  margin  the  epidermis  is  continued  insensibly  into  the  epithe- 
lium of  the  mucous  membrane,  and  little  islands  of  it  are  situated  on 
the  mucous  surface  —  in  fact,  there  is  a  tendency  for  the  epithelium  to 
change  into  epidermis. 

Around  the  ectopion  the  cutaneous  surface  is  marked  by  irregular 
cicatrices  which  are  considered  to  be  relics  of  the  allantois.  Above  the 
ectopion  is  a  median  depression — due  to  the  want  of  the  linea  alba  —  as 
high  as  the  umbilicus.  The  umbilicus  may  indeed  blend  with  the  ecto- 
pion ;  if  not,  it  is  generally  very  close  to  it.  The  umbilical  vein  is  conse- 
quently elongated ;  the  urachus  and  umbilical  arteries  are  proportionately 
shortened. 

In  the  female  there  is  a  separation  of  the  labia  majora,  of  the  two 
sides  of  the  clitoris,  and  of  the  labia  minora.  The  external  orifice  of  the 
vagina  is  a  mere  antero-posterior  slit ;  and  in  some  cases  the  sex  of  the 
infant  is  doubtful.  The  vagina  and  uterus  are  sometimes  bifid.  The 
anus  is  often  placed  farther  forward  than  normal.  One  of  the  most  im- 
portant features  is  detected  Ijy  pressing  upon  the  pubic  region,  when  a 
wide  separation  of  the  pubic  bones,  varying  from  l^-  to  six  inches  (3  to 
12  centimetres),  will  be  recognised.  It  is  quite  exceptional  for  the  pubes 
to  be  united  at  the  symphysis. 

By  rectal  examination  much  is  learnt ;  namely,  the  very  forward  pro- 


DISEASES    OF   THE   FEMALE   BLADDER   AND    URETHRA       931 

jection  of  the  sacrum,  whereby  the  antero-posteiior  diameter  of  the  pelvis 
is  diminished.  With  the  finger  in  the  rectum,  and  the  other  hand  on 
the  hypogastrium,  one  feels  the  posterior  surface  of  the  ectopic  bladder, 
and  the  separation  of  the  pubes  is  still  more  distinctly  perceived. 

Dissection  shows  the  perineal  muscles  to  be  ill-developed,  and  the 
sphincter  vesicse  to  be  absent  —  at  least,  in  one  instance  only  does  it 
seem  that  a  sphincter  of  the  urethro-vesical  orifice  has  been  found.  In 
place  of  the  symphysis  is  a  fibrous  band  of  varying  thickness  and 
resistance. 

Nothing  but  a  layer  of  cellular  tissue,  and  not  always  so  much 
as  this,  separates  the  vesical  mucous  membrane  from  the  peritoneal 
coat. 

The  conditioii  of  the  ureters  is  very  important.  Following  them 
from  the  bladder  wall,  they  dip  down  into  the  pelvis  before  turning  \ip 
towards  the  kidneys.     They  are  frequently  elongated  and  dilated. 

Symptoms.  —  Individuals  with  ectopion  vesicae  may  be  otherwise 
well  formed  and  robust:  most  frequently,  however,  they  are  thin,  weakly, 
and  constantly  suffering ;  as  the  slightest  friction  from  their  linen  in- 
flames the  vesical  mucous  membrane.  Thus  they  often  die  from 
ascending  inflammation  ending  in  suppurative  pyelophlebitis. 

As  a  result  of  the  constant  trickling  of  urine  they  are  always  wet 
and  in  discomfort,  and  frequently  affected  Avith  erythema,  excoriations, 
erysipelas,  or  more  deeply  seated  inflammation  of  the  skin  and  tissues 
around.  Thus  they  are  always  in  danger  of  mischief  ascending  to  the 
kidneys.  Sexual  appetite,  as  a  rule,  does  not  exist.  In  the  female  con- 
ception has  occurred,  the  offspring  being  naturally  formed;  but  delivery 
is  often  difficult,  and  confinement  almost  always  followed  by  prolapse 
of  the  uterus.  j\Iany  malformations  of  the  vagina  coexist,  especially  in 
connection  with  the  anus.  Double  inguinal  hernia  is  very  common. 
Sometimes  the  ileum  terminates  in  the  bladder.  Prolapse  of  the  rectum 
or  uterus,  club  foot,  harelip,  anencephalus,  and  spina  bifida  have  also 
been  recorded.  Ectopion  vesicse  is,  happily,  very  rare.  jSTeudorfer  com- 
putes its  occurrence  as  twice  in  100,000  infants  :  nine-tenths  of  the  cases 
of  ectopion  vesica?  die  Avithin  a  few  days  of  birth.  Ectopion  is  not, 
however,  incompatible  Avith  long  life,  as  instances  are  recorded  of  in- 
dividuals so  affected  attaining  the  age  of  40,  50,  and  even  70  years. 

Treatment.  —  It  must  suffice  here  to  name  the  modes  of  operation 
performed :  — 

(i.)  To  establish  a  fistulous  communication  betAveen  the  ureters  and 
rectum;  or  (ii.)  BetAveen  the  bladder  and  the  rectum.  The  mortality  of 
these  two  methods  has  been  40  per  cent,  (iii.)  The  autoplastic  or  flaps 
method.  IMortality,  14-G  per  cent.  This  method  has  in  several  cases 
cured  the  coexisting  inguinal  hernias,  (iv.)  The  removal  by  dissection, 
or  the  destruction  by  escharotics  of  the  mucous  membrane  of  the  bladder, 
except  around  the  orifices  of  the  ureters.  Sonneburg,  after  dissecting  ofl:' 
the  bladder  mucous  membrane,  sutures  the  mucous  membrane  to  the  base 
of  the  epispadias,    (v.)  To  close  the  bladder  by  suturing  its  tAvo  margins. 


932  SVSTEA/   OF  GYN.-ECOLOGY 

This  method  is  sometimes  combined  with  closure  of  the  interval  at  the 
symphysis  pubis,  after  the  manner  of  Trendelenburg. 

According  to  Tufiier  the  alternatives  are  as  follows :  When  the  case 
is  one  of  .epispadias,  with  a  small  fissure  at  the  symphysial  area  of  the 
bladder,  close  the  urethra  and  neck  of  the  bladder  by  uniting  the  edges 
of  these  parts.  So,  too,  if  the  defect  of  the  bladder  extends  somewhat 
higher,  the  edges  of  the  bladder  should  be  freshened  after  dissecting  up 
the  mucous  membrane  without  damage  to  the  ureters.  If  the  ectopion  is 
complete  and  the  separation  of  pubes  considerable,  divert  the  urine 
into  the  rectum.  In  a  young  and  vigorous  person  employ  Dubois  and 
Dupuytren's  method,  which  consists  in  suturing  together  the  margins  of 
the  bladder.  If  the  genital  organs  be  atrophied,  or  the  patient  weakly, 
or  affected  by  other  malformations,  suture  the  mucous  membrane  to  the 
root  of  the  urethra ;  or  establish  a  recto-vesical  fistula  and  destroy  the 
mucous  membrane  of  the  bladder. 

As  regards  the  autoplastic  methods,  the  simple  flap  is  inferior  to  the 
methods  by  several  flaps ;  and  the  method  whereby  the  flaps  are  super- 
posed is  better  than  that  by  which  they  are  simply  joined  together. 

FuxcTioxAL  Disturbances  of  the  Bladder. —  i.  Functional  Dis- 
ease due  to  Structural  Disease  of  the  Nervous  System.  —  (a)  Tabes  dorsalis. 
—  (i.)  On  the  motor  side  there  may  be  paralysis  without  retention. 
This  paralysis  shows  itself  in  a  delay,  varying  from  a  minute  to  a 
quarter  of  an  hour,  in  starting  to  micturate ;  the  flow  may  then  stop,  to 
go  on  again  after  an  .interval,  and  within  an  instant  or  two  after  the 
act  seems  to  be  completed,  urine  may  be  passed  into  the  clothes,  (ii.) 
Paralysis  culminating  in  complete  or  partial  retention,  (iii.)  Inter- 
mittent incontinence,  which  may  be  due  to  overflow  of  urine  from  the 
bladder ;  or  be  caused  by  a  peculiar  irritability  of  the  bladder,  which 
leads  to  a  slight  discharge  of  urine  directly  the  patient  makes  a  move  to 
micturate,  (iv.)  An  urgent  necessity  to  pass  water,  due  to  tenesmus, 
accompanied  perhaps  by  cystalgia. 

On  the  sensory  side  are,  in  the  ''  excess "  direction,  urethralgia, 
cystalgia,  vesical  colic  ;  in  the  "  insufficiency  "  direction,  anaesthesia  of 
the  urethro-vesical  mucous  membrane,  and  the  loss  of  muscular  sense  of 
these  organs.  The  vesical  colic,  analogous  to  the  gastric  colic,  and  preceded 
by  crises  of  variable  duration  and  intensity,  is  attended  by  excessive 
pain.  The  anaesthesia  of  the  urethro-vesical  mucous  membrane  and  of 
the  muscular  sense  is  manifested  by  the  want  of  consciousness  of  the 
passage  of  urine  or  of  the  distension  of  the  bladder.  Such  patients 
urinate  in  a  routine  manner  at  stated  intervals,  not  because  they  have  a 
sense  of  necessity  or  any  desire  to  empty  the  bladder :  they  must  watch 
in  order  to  know  whether  they  are  passing  water  or  not,  and  when  they 
have  finished;  some  of  these  patients  cannot  micturate  in  the  dark. 

0))  Potfs  disaase,  and  injuries  to  the  brain  ayid  spinal  cord,  by  interfer- 
ing with  the  vesico-urethral  nerve  centres,  cause  paralysis  with  retention, 
and  the  incontinence  of  retention  or  overflow.     Disturbances  from  such 


DISEASES   OF  THE   FEMALE  BLADDER  AND    URETLIRA        933 

causes  are  very  familiar.     So,  too,  are  the  similar  disturbances  from 
serious  injuries  to  the  brain. 

(c)  In  general  paralysis,  according  to  Geffrier,  there  is  retention 
from  urethral  spasm  during  the  stage  of  excitement,  and  retention  from 
paralysis  during  the  period  of  depression. 

(d)  In  certain  cases  of  insanity  the  retention  is  voluntary,  the  patients 
refusing  to  pass  water  just  as  they  refuse  to  take  food. 

{e)  Injxitcliy  sclerosis  retention  due  to  spasms  of  the  urethra  is  caused 
by  the  irritation  of  the  lumbar  centre  for  the  sphincter  of  the  bladder. 

2.  Functional  Disturbances  of  the  Bladder  connected  with  Epilepsy. — 
The  principal  of  these  is  incontinence.  It  differs  from  conunon  noc- 
turnal incontinence  in  its  occasional  occurrence,  and  by  the  patient 
awaking  with  a  feeling  of  extreme  weakness,  exhaustion,  and  weight 
in  the  head,  and  with  the  tongue  sore  or  bleeding.  Incontinence  some- 
times occurs  during  a  fit  of  hysteria. 

In  hysteria  there  is  occasionally  anaesthesia,  with  spasm  of  the  neck  of 
the  bladder ;  there  is  great  difficulty  in  beginning  to  micturate,  and  this 
may  increase  to  complete  retention.  In  some  hysterical  subjects  there  is 
involuntary  discharge  of  urine  under  strong  emotion,  due  to  spasm  of  the 
detrusor  fibres  of  the  bladder.  Hysterical  retention,  due  to  paralysis  of 
the  bladder,  is  frequent;  it  is  sometimes  accompanied  by  hysterical  hemi- 
plegia, or  more  often  by  paraplegia.  If  the  paralysis  affect  both  the 
detrusor  and  the  sphincter  vesicae,  these  patients  get  the  incontinence  of 
retention. 

3.  Functional  troubles  connected  with  congenital  malformations,  and, 
4,  those  due  to  neighbouring  organs,  make  what  is  often  described  as 
the  irritable  bladder. 

The  sensory  symptoms  are  cystalgic  pains ;  the  motor  symptoms, 
frequent  spasms  of  the  bladder  and  urethra,  which  cause  frequent,  but 
slow  and  painful  micturition,  urgent  calls  to  pass  water,  and  sometimes 
actual  retention. 

The  causes  of  the  symptoms  are  congenital  atresia  urethrae,  fissure 
of  the  anus,  haemorrhoids,  operations  on  the  anus,  intestinal  worms; 
or  uterine,  ovarian,  vaginal  and  vulvar  disorders  ;  or  operations  on  these 
parts. 

5.  Functional  Vesical  Troubles  due  to  Lesions  of  the  Bladder.  —  The 
reflex  irritation  caused  by  vesical  calculus,  tumour,  or  fissure  of  the 
urethra  in  women  produces  vesical  tenesmus  analogous  to  rectal  tenes- 
mus from  anal  fissure.  A  deep-seated  but  slight  urethritis  near  the 
neck  of  the  bladder  often  causes  cystalgia.  These  causes  of  painful  and 
irritable  bladder  must  be  recognised  in  order  to  treat  them  successfully. 

6.  Functional  Vesical  Troubles  caused  by  the  Condition  of  the  Urine.  — 
The  excess  of  limpid  urine  in  hysterical  women,  urates  in  the  gouty, 
and  of  phosphates  in  neurotic  persons,  and  any  urine  which  is  extremely 
acid,  are  well-known  causes  of  irritable  bladder. 

7.  Idiopathic  functional  disturbances  of  the  bladder,  such  as 
cystalgia,  and  spasms  both  of  the  vesical  muscle  and  the  compressor 


934  SYST£M  OF  GYN/ECOLOGY 

urethrae,  sometimes  seem  to  occur  independently  of  any  ascertainable 
cause.  True  idiopathic  cystalgia,  Taffier  writes,  occurs  in  persons  whose 
parents  are  the  subject  of  nervous  or  rheumatic  migraine  and  who  are 
themselvfes  neurotic.  The  determining  causes  are  cold,  damp,  changes  of 
season,  constipation,  voluntary  retention,  and  irritability  of  the  genital 
organs. 

8.  Functional  Vesical  Troubles  of  Mental  Origin.  —  The  enormous 
influence  of  the  mind  over  the  functions  of  the  bladder  are  proverbial. 
That  polyuria,  as  well  as  frequency  of  micturition,  is  due  to  mental  in- 
fluence is  proved  by  the  fact  that  if  the  mind  is  engaged  and  interested 
both  cease  as  they  do  during  sleep.  The  patients  may  pass  water  fifty 
times  a  day,  yet  sleep  all  through  the  night.  A  greatly  increased  capacity 
of  bladder  is  proved  to  exist  in  these  cases  by  the  capacity  for  injections 
of  warm  water ;  and  yet  a  catheter  left  in  the  bladder  as  a  drain-tube 
does  not  remove  the  desire  these  patients  have  to  pass  water. 

Another  form  of  functional  disturbance  from  mental  causes  is  urethral 
spasm,  manifested  either  during  micturition  or  during  the  introduction  of 
an  instrument.  If  it  occur  during  micturition  we  have  the  condition  so 
happily  described  by  Sir  James  Paget  as  "  stammering  of  the  bladder," 
which  renders  the  person  incapable  of  micturating  in  presence  of  others, 
or  even  in  a  place  where  the  flow  of  their  urine  can  be  heard. 

Even  when  there  is  no  ascertainable  lesion  about  the  urinary  organs 
to  explain  this  troublesome  condition,  there  are  still  many  other  causes  of 
incontinence  both  in  children  and  adults  for  which  search  must  be  made. 

Incontinence  of  urine  assumes  two  very  distinct  and  different  forms 
—  (i.)  the  incontinence  of  the  drop-by-drop  kind,  the  incessant,  con- 
tinuous dribbling;  and  (ii.)  incontinence  in  the  form  of  intermittent 
large  evacuations  of  urine. 

(a)  The  "  continual "  incontinence  consisting  in  incessant  dribbling 
of  urine  is  due  to  paralysis  of  the  vesical  and  urethral  (the  membranous 
urethra)  sphincters.  It  may  or  may  not  be  associated  with  retention.  If 
it  is,  the  incontinence  is  merely  the  overflow  of  the  bladder  and  is  the 
"  incontinence  of  retention."  If  it  is  "  incontinence  without  retention," 
the  bladder  is  no  longer  serving  as  a  reservoir,  but  has  become  merely  a 
part  of  a  conduit  placed  between  ureters  and  urethra.  This  is  a  state 
of  absolute  incontinence.  '■'•  Continual  "  incontinence,  if  it  has  not  been 
caused  by  over-distension  and  its  effects  on  bladder  and  sphincter,  is 
probably  always  hysterical. 

ih)  Some  children  have  nocturnal  incontinence  AV'hose  urinary  functions 
during  the  day  are  quite  normal  in  every  respect.  These  are  the  subjects 
of  incontinence  of  a  psychopathic  (mental)  origin,  and  they  constitute  the 
majority  of  cases.  It  is  intermittent  incontinence  of  large  quantities 
of  urine :  it  arises  from  the  child  having  a  besetting  dream  of  passing 
water,  and  it  is  aggravated  by  the  fear  that  she  will  wet  her  bed.  This 
form  of  incontinence  always  ceasc^s  at  puberty  if  not  before,  when  a  dif- 
ferent turn  is  given  to  the  thoughts  and  dreams  of  these  incontinents. 


DISEASES   OF  THE  FEMALE  BLADDER  AND    URETHRA       935 

(c)  In  another  class  of  cases  there  is  incontinence  of  the  intermittent 
form  occurring  at  night  only ;  but  during  the  day  these  children  have 
frequent  and  pressing  calls  to  pass  urine,  and  must  give  immediate  relief 
to  their  bladders,  otherwise  they  wet  their  clothes.  This  form  is  due  to 
irritation  either  of  the  spinal  cord,  of  the  intestines,  or  of  the  genito- 
urinary apparatus.  Contracted  meatus,  oxaluria  and  lithsemia,  and 
intestinal  worms  play  an  important  part  in  it. 

(d)  In  another  class  of  cases  the  children  have  both  diurnal  and 
nocturnal  incontinence.  They  never  think  for  an  instant  of  trying  to 
prevent  it.  They  pass  water  in  the  daytime  with  the  same  unconscious- 
ness as  prevails  at  night.  This  form  is  due  either  to  defective  contractile 
power  in  the  urethral  sphincter,  or  to  urethral  insensibility.  In  adults 
this  may  occur  in  consequence  of  hysteria,  of  overstretching  of  the 
sphincter  by  too  large  an  instrument,  or  by  digital  examination.  It  also 
occurs  as  a  consequence  of  spinal  lesions,  especially  tabes  dorsalis. 

(e)  During  epileptic  seizures  incontinence  takes  place  at  the  end  of  the 
attack,  whether  it  occur  by  night  or  day.  It  is  succeeded  by  a  feeling  of 
extreme  prostration  and  evidence  of  the  tongue  or  cheek  havingbeen  bitten. 

All  forms,  except  the  epileptic,  have  a  tendency  to  disappear  at 
puberty.  After  twenty-live  years  of  age  they  are  quite  exceptional,  if 
not  altogether  unknown.  Spontaneous  cure  sometimes  unexpectedly 
follows  an  attack  of  fever  or  some  other  illness.  In  some  cases,  after 
the  incontinence  ceases,  these  persons  are  obliged  to  pass  water  once  or 
twice  during  the  night ;  and  this  necessity  may  continue  even  throughout 
life.  Many  of  them,  however,  get  cured  of  their  incontinence,  only  to 
become  the  prey  of  some  other  nervous  affection  such  as  spasm  of  the 
bladder,  or  irritable  bladder,  or  to  become  confirmed  hypochondriacs. 

Treatment.  —  In  the  psychopathic  form  moral  treatment  is  the  only 
useful  one.  The  little  patient  must  not  be  scolded,  or  punished,  or 
reproached,  or  made  a  laughing-stock.  She  should  be  encouraged, 
reassured,  and  even  told  not  to  mind  the  accident.  Let  her  not  go  to 
sleep  with  a  final  instruction  that  she  must  not  wet  herself,  whereb}'  her 
last  thought  is  made  a  connecting-link  with  her  habitual  dream.  On  the 
contrary,  coax  her,  if  possible,  into  the  hope  that  she  is  cured ;  and  assure 
her  she  ought  not  to  be  troubled  if  she  should  find  she  is  not.  Much  is 
gained  if  a  few  nights  pass  "without  an  accident,  and  this  is  sometimes 
obtained  by  waking  the  child  just  before  the  hour  at  which  the  nurse  has 
ascertained  that  micturition  takes  place.  Means  are  sometimes  recom- 
mended to  lighten  sleep  and  increase  the  irritabilit}^  of  the  neck  of  the 
bladder.  A  hard  bed,  a  little  tea  or  coffee  taken  late  before  going  to 
bed,  are  calculated  to  obtain  the  one  aim,  and  the  passage  of  catheters 
or  sounds  will  sometimes  accomplish  the  other.  [For  treatment  by  elec- 
tricity, vide  Sijstem  of  Med.  vol.  i.  p.  372.] 

For  incontinence  due  to  irritable  bladder  the  treatment  consists  in 
the  removal  of  the  cause  ;  thus  vermifuge  remedies  and  improvement  in 
dietary  to  correct  oxyluria  or  lithiasis,  are  among  the  means  which  will 
be  employed. 


936  SVSTEM   OF  GYNECOLOGY 

Incontinence  from  atony,  or  from  paralysis,  will  be  often  rapidly 
cured  by  electrolysis  applied  to  the  hypogastrium,  or  even  within  the 
cavity  of  the  bladder. 

Cystitis.  —  I.  Acute  cystitis  in  the  female,  though  less  frequent  than 
in  the  male,  is  nevertheless  far  from  rare.  The  absence  of  the  prostate 
and  of  the  retaining  influence  of  the  male  urethra,  are  largely  accountable 
for  this.  Other  causes,  such  as  gonorrhoea,  tuberculosis,  calculus,  and 
neoplasms,  are  common  to  both  sexes  ;  while  the  proximity  of  the  uterus 
and  the  tendency  of  the  bladder  to  sympathise  with  its  diseases  and  dis- 
placements add  a  new  set  of  causes  in  the  female. 

The  physiological  solidarity  which  subsists  between  the  two  organs  is 
due  not  only  to  the  close  relationship,  but  to  the  remarkably  free  vascular 
communications  which  exist  between  them.  In  certain  cases,  therefore, 
the  bladder  is  subject  not  only  to  compression  but  to  hyperaemia  by 
extension  due  to  this  vascular  connection.  In  addition  to  the  fact  that 
the  main  vesical  and  the  main  uterine  arteries  arise  from  the  hypogastric 
trunk  there  is  a  free,  direct  distribution  of  smaller  artex-ioles  from  the 
anterior  aspect  of  the  uterus,  and  the  vesical  and  anterior  uterine  veins 
actually  unite.  Observation  shows  that  there  is  some  increased  frequency 
of  micturition,  associated  in  some  cases  with  a  slight  amount  of  dysuria, 
just  before  and  after  the  occurrence  of  the  catamenia:  this  is  more 
marked  in  multiparas  and  in  cases  of  subinvolution  of  the  uterus. 

It  is  found  also  that  cases  of  chronic  cystitis  commonly  exhibit  exacerba- 
tions at  these  periods  (West,  Laugier,  Bernardet) ;  and  a  similar  increase 
is  noticed  with  suppression  of  menses  or  at  the  menopause  (Civiale). 

During  gestation  there  is  an  increased  vascularity  of  the  neighbouring 
parts,  which  is  readily  observed  in  the  vagina  and  vulva,  and  depends  on 
increase  in  the  size  and  number  of  the  veins  and  arteries,  as  well  as  on 
dilatation  of  capillaries ;  thus  is  produced  the  so-called  vaginal  pulse, 
appreciable  by  the  finger  (Oisander),  which  extends  also  to  the  bladder. 
Frequent  micturition  in  the  early  months  of  pregnancy,  before  there 
has  been  any  notable  enlargement  of  the  uterus,  is  so  habitual  that  it  is 
scarcely  complained  of.  More  than  50  per  cent  of  women  experience 
this  increase  in  frequency,  pain  and  slight  haemorrhage,  but  they  are 
most  marked  in  primiparas. 

Cystitis  associated  with  chronic  inflammatory  conditions  of  the  uterus 
is  most  rebellious  to  treatment,  and  often  disappears  only  with  subsidence 
of  the  uterine  disease  ;  in  cases  of  urinary  trouble,  of  which  the  pathology 
seems  obscure,  the  uterus  should  always  be  carefully  examined.  The 
mechanical  influence  of  pressure  by  the  uterus  or  its  contents  leads  both  to 
diminished  capacity  and  to  congestion,  which  result  in  greater  irritalnlity 
of  the  bladder  and  need  for  emptying  it.  This  is  most  marked  when 
there  is  forcil)]e  and  continuous  pressure  from  the  head  of  the  fojtus  or 
dystocia,  particularly  if  tlie  pelvis  be  narrow;  in  pi'olonged  labour  this 
pressure,  though  short  of  producing  contusion  and  sloughing,  may  lead  to 
cystitis. 


DISEASES   OF  THE  FEMALE  BLADDER  AND    URETHRA       937 

Compression  differently  applied  so  as  to  lead  to  retention  of  urine  is 
a  fruitful  source  of  cystitis.  Tumours,  displacements  of  the  uterus,  or 
even  inflammatory  exudations,  causing  compression  between  them  and 
the  symphysis  pubis,  interfere  with  the  escape  of  the  urine,  produce  both 
congestion  and  distension  of  the  bladder,  and  may  lead  to  incontinence, 
rupture,  or  grave  inflammation.  Such  cases  require  gradual  evacuation 
of  the  bladder  and  removal  of  the  pressure.  It  is  here,  for  the  most 
part,  that  a  peculiarly  intense  form  of  cystitis  occurs  characterised  by 
expulsion  of  membrane  in  the  form  of  a  sac  moulded  to  the  internal 
surface  of  the  bladder. 

Cystitis  in  woman,  then,  is  met  with,  particularly  at  the  menstrual 
periods  ;  at  the  menopause  ;  in  connection  with  a  congested  state  of  the 
uterus  from  pathological  causes ;  in  early  pregnancy,  influenced  by  the 
extension  of  hypersemia  or  by  retroversion  and  consequent  retention  of 
urine ;  and  towards  the  end  of  gestation  owing  to  malformation  or  mal- 
position of  the  foetus.  Postpuerperal  cystitis,  wdiich  is  generally  the 
most  severe,  may  be  due  to  direct  toxic  infection,  to  fissure  of  the  neck 
of  the  bladder,  or  even  to  the  use  of  a  septic  catheter.  Apart  from 
pregnancy  cystitis  may  be  set  up  by  cold,  excessive  coitus,  or  voluntary 
over-distension  of  the  bladder. 

Etiology. — The  causes  of  acute  cystitis  are  (a)  remote  and  (Jj)  im- 
mediate.    The  remote  are  either  general  or  local. 

Certain  constitutional  conditions  favour  the  occurrence  of  the  disease : 
these  are  commonly  stated  to  be  rheumatism,  gout,  and  tubercle. 

Cold,  improper  food,  and  defective  hygiene  are  also  regarded  among 
the  causes  of  a  remoter  kind. 

The  composition  of  the  urine  sometimes  disposes  to  cystitis ;  it  is  in 
this  manner,  no  doubt,  that  gout  is  a  cause  of  it.  The  toxic  state  of  the 
urine  in  fever  patients,  as  Avell  as  the  retention  of  urine  which  often 
affects  them,  induces  congestion  of  the  bladder.  Cantharides,  and  some 
other  drugs  which  are  eliminated  by  the  kidneys,  by  passing  over  the 
mucous  membrane  of  the  bladder,  have  a  distinct  power  to  cause  fre- 
quency and  pain  in  micturition. 

Immediate  Causes.  —  These  are  catheterism,  gonorrhuja,  vaginitis, 
and  other  infective  processes  about  the  vulva  and  external  urethral 
orifice.  They  all  produce  cystitis  by  provoking  a  direct  microbic  infec- 
tion of  the  vesical  mucous  membrane  by  means  of  the  secretion  and  dis- 
charges conveyed  to  the  bladder  from  the  urethra. 

rathologj/.  —  The  first  changes  in  cj-stitis  are  a  pronounced  injection 
of  the  ])lood-vessels  of  the  mucous  membrane,  especially  about  the 
ureteral  orifices  and  the  neck  of  the  bladder.  As  the  inflammation 
advances  the  mucous  membrane  swells,  takes  a  bright  crimson  colour, 
and  the  distinct  outline  of  the  distended  arborescent  vessels  disappears. 
Microscopically,  the  epithelial  cells  are  swollen,  their  nuclei  are  broken 
up,  and  the  rete  mucosum  is  infiltrated  with  leucocytes  and  embryonic 
cells.  The  muscular  coat  is  sometimes  similar!}'  infiltrated.  Abscesses, 
ulcers,  and  gangrene  may  result. 


938  SYSTEM   OF  GYNECOLOGY 

The  bacteriological  study  of  cystitis  goes  to  show  that  several  forms 
of  pyogeuetic  bacteria  are  capable  of  exciting  cystitis ;  but  the  microbe 
■which  has  been  most  generally  met  with  is  the  bacterium  coli  commune. 
Others  are  the  uro-bacillus  liquefaciens  and  the  ordinary  agents  of  sup- 
puration ;  and,  very  much  more  rarely,  the  bacillus  griseus,  the  micro- 
coccus albicans  ampins,  and  the  diplococcus  favus.  In  men  and  women 
it  is  the  colon  bacillus  which  is  most  frequently  found,  and  which  is, 
indeed,  in  men  the  agent  of  almost  all  cases  of  cystitis ;  but  in  women 
the  staphylococci,  as  the  elements  exciting  puerperal  and  post-partum 
cystitis,  are  met  Avith  almost  as  frequently  as  the  colon  bacillus.  In 
cystitis  from  gonorrhoea,  as  well  as  from  other  causes,  the  same  bacteria 
are  found ;  it  is  quite  exceptional  to  meet  with  gonococci. 

Symptoms. — These  are  frequent  micturition  —  the  desire  being  so 
imperative  that  the  action  of  the  bladder  cannot  be  controlled,  though 
but  a  small  quantity  of  urine  may  be  present ;  considerable  smarting 
followed  by  some  pain  after  the  bladder  is  emptied ;  and  the  presence  of 
pus  and  sometimes  of  blood  in  the  urine,  often  only  at  the  end  of  micturi- 
tion. Acute  cystitis  appears  in  two  very  different  degrees ;  one  almost 
insufferable  to  the  patient  and  alarming  to  witness,  the  other  much  less 
severe  and  dangerous. 

The  severity  and  duration  of  the  symptoms  are  very  variable. 
Attacks  occurring  during  pregnancy  are  usually  very  benign,  while 
those  following  delivery  are  even  more  severe  and  prolonged  than 
cystitis  occurring  in  man.  Apart  from  pregnancy  inflammation  of  the 
bladder  undergoes  exacerbation  at  the  catamenial  periods. 

Besides  the  above  functional  symptoms  there  are  certainp7i?/sicaZsig'ns 
due  to  the  condition  of  the  bladder.  These  are :  (1)  pain  and  tender- 
ness over  the  trigone  felt  on  digital  examination  through  the  vagina ; 
this  pain  is  much  accentuated  if  at  the  same  time  pressure  be  made  over 
the  hypogastrium.  (2)  Intravesical  tenderness.  Usually  in  passing  a 
catheter  the  discomfort  experienced  by  the  pressure  of  the  beak  of  the 
instrument  along  the  urethra  ceases  at  once  after  its  entrance  into  the 
bladder;  but  when  cystitis  exists,  pain  is  aggravated  by  the  presence  of 
the  instrument  within  the  neck  of  the  bladder.  (3)  Distension  of  the 
bladder  with  an  antiseptic  solution.  If  this  is  attempted,  intense  pain, 
accompanied  with  uncontrollable  desire  to  empty  the  bladder,  follows 
the  injection  of  a  very  small  quantity. 

As  regards  the  question  of  temperature,  M.  Guyon  has  pointed  out 
that  there  is  no  fever  in  acute  cystitis,  that  the  most  painful  forms  of 
the  disease  show  no  elevation  of  temperature  whatever,  and  that  as  soon 
as  a  febrile  temperature  appears  in  a  patient  with  cystitis,  it  is  certain 
that  there  is  some  perivesical,  or,  much  more  commonly,  some  uretero- 
renal  inflammation. 

7V/.«  mefJiod  of  examination  in  these  cases  is  direct  exploration  by  the 
finger  in  the  vagina  or  by  the  hand  on  the  hypogastrium — or  by  the 
two  combined.  In  this  way  the  site  and  degree  of  tenderness  may  be 
ascertained.     In  certain  acute  cases  the  introduction  of  the  finger  into 


DISEASES    OF   THE   FEMALE   BLADDER   AND    URETHRA        939 

the  vagina,  or  the  mere  pressure  of  the  hand  on  the  hypogastrium,  pro- 
vokes extreme  suffering.  In  less  severe  instances  the  thickness  of  the 
inflamed  walls  may  be  gauged  by  the  combined  method  ;  or  this  may  be 
arrived  at  by  pressure  of  the  finger  forwards  against  the  pubes.  The 
introduction  of  the  sound  into  the  bladder  also  may  demonstrate  the 
exact  points  and  degree  of  tenderness. 

Diagnosis.  —  The  affection  as  a  rule  is  easily  diagnosed  by  the  three 
classical  symptoms  :  frequency  of  micturition ;  painful  micturition  ;  and 
pyuria.  The  presence  of  all  three  of  them  is  necessary.  No  one  of 
them,  taken  alone,  can  establish  a  right  diagnosis. 

It  is  not  by  the  amount  or  character  of  the  sediment,  but  by  the 
pain  and  tenderness  on  pressure  per  vaginam,  and  the  fact  that  the  first 
and  last  portions  of  the  urine  contain  most  pus,  that  we  diagnose  the 
cystitis  to  be  of  the  neck  and  trigone  of  the  bladder.  When  the  whole 
of  the  bladder  surface  is  alike  involved  the  pus  is  uniformly  diffused 
through  all  the  urine. 

The  cause  of  the  cystitis  ought  always  to  be  ascertained,  and  this 
can  easily  be  done  in  the  case  of  calculus  or  new  growth.  The  chief 
difficulty  consists  in  distinguishing  tubercular  cystitis  in  its  early  stage 
from  cystitis  due  to  a  chronic  urethral  discharge.  The  family  history 
of  the  patient,  the  bacteriological  tests  by  means  of  the  microscope  or 
bacilli  culture,  and  the  presence  of  tubercular  deposit  in  other  parts, 
will  give  the  clue  to  the  cause. 

Pericystitis  will  be  diagnosed  by  the  high  temperature,  by  the  tume- 
faction felt  through  vagina  or  above  the  symphysis  pubis,  which  is  not 
removed  by  using  the  catheter,  and  by  the  signs  of  deep-seated  sup- 
puration.    It  is  very  rare. 

A  frequent  desire  to  micturate,  apart  from  any  fever  or  alteration  in 
the  character  of  the  urine,  may  be  met  with  in  cystocele ;  but  this  con- 
dition is.  readily  recognised,  on  examination,  by  a  bulging  into  the 
vagina,  and  by  the  ability  to  recognise  the  sound  when  introduced  in 
the  pouch. 

The  presence  of  pus  in  the  urine,  which  is  one  of  the  prominent 
features  of  cystitis,  may  be  met  with  on  account  of  vaginal  discharges; 
but  the  other  symptoms  are  absent,  and  on  closer  examination  the 
source  of  the  discharge  should  be  discovered. 

The  differential  diagnosis  of  the  various  forms  of  cystitis  is  a  very 
much  more  tedious  and  difficult  affair.  A  matter  of  the  first  importance 
is  a  methodical  examination  of  the  uterus  and  its  appendages ;  so  fre- 
quently does  the  bladder  participate  in  vascular  disturbances  of  this 
organ.  It  is  also  necessary  to  search  for  any  evidence  of  gonorrhoea 
either  in  the  patient  or,  if  she  be  married,  in  her  husband.  The  recog- 
nition of  pregnancy  again,  in  association  with  comparatively  mild  mani- 
festations, is  a  sufficient  indication  of  the  probable  cause  of  the  malady. 
A  bacteriological  investigation  of  the  purulent  dejwsit  in  the  urine  should 
be  undertaken  in  prolonged  or  severe  cases  with  a  view  of  discovering 
the  gonococeus  or  the  tubercle  bacillus  ;  but  the  must  important  means 


940  SVST£A/   OF  GYNECOLOGY 

of  ascertaining  any  local  condition  consists  in  the  bimanual  examination 
of  the  bladder,  and  in  the  introduction  of  the  finger  into  the  bladder 
through  the  dilated  urethra.  This  is  undoubtedly  the  best  means  of 
discovering  any  foreign  body,  new  growth,  or  morbid  condition  of  the 
bladder  wall. 

Treatment.  —  The  cause  of  the  cystitis  must  be  removed  as  soon  as 
possible,  and  the  treatment,  in  appropriate  cases,  should  be  directed 
towards  the  uterus  where  this  is  also  affected.  Cases  associated  with 
pregnancy  are  not  usually  severe,  and  the  termination  of  gestation  may 
lie  counted  upon  to  end  the  cystitis.  Baths,  narcotics,  and  balsamic 
drugs  are  beneficial ;  but  in  really  severe  cases  there  is  no  remedy  to  be 
compared  with  injections  of  a  few  drops  of  silver  nitrate  (1-500),  repeated 
at  such  intervals  as  give  the  pain  of  its  introduction  time  to  subside. 

The  most  severe  cases  can  only  be  relieved  by  dilatation  (digital)  of 
the  urethra,  or  even  by  a  vesico-vaginal  section. (kolpocystotomy)  which 
gives  the  bladder  complete  physiological  rest. 

II.  Chronic  Cystitis.  —  As  a  rule  cystitis  in  woman  is  of  the  chronic 
form ;  though  some  of  the  most  acute  cases  I  have  witnessed  have 
occurred  in  women  after  parturition. 

The  cystitis  attributed  to  rheumatism  and  gout,  as  well  as  tuber- 
cular cystitis,  is  of  a  slow  and  persistent  kind. 

Morbid  Anatomy. — The  mucous  membrane  of  the  bladder  is  of  a 
slate  colour,  ecchymosed  in  places,  marbled  purplish,  blackish,  or  green- 
ish, and  covered  with  an  adherent  layer  of  muco-pus.  Sometimes  there 
are  large  or  small  ulcers  on  the  surface.  The  changes  in  the  mucous 
membrane  affect  the  bladder  throughout,  but  are  most  marked  about 
the  trigone,  and  least  so  about  the  base  of  the  bladder.  The  mucous 
membrane  is  softened,  thickened  and  swollen,  and  sometimes  small  ab- 
scesses are  present  both  in  the  membrane  and  beneath  it.  The  epi- 
thelium is  exfoliated,  the  basement  membrane  infiltrated,,  and  the 
capillaries  hypertrophied.  The  muscular  coats  are  thickened.  The 
different  conditions  presented  by  the  mucous  membrane  have  given 
rise  to  names  as  various.  Thus  are  described  ulcerative  cystitis,  gan- 
grenous cystitis,  "  croupous  cystitis  "  (that  is,  cystitis  attended  with  the 
production  of  false  membranes),  and  the  villous  form  of  cystitis  (cystite 
fungo-vasculaire).  To  name  these  varieties  is  to  indicate  the  different 
aspects  the  mucous  membrane  may  present. 

In  the  croupous  cystitis  the  false  membrane  is  of  a  yellowish  colour; 
it  is  composed  of  fibrinous  material,  containing  in  its  substance  leuco- 
cytes and  epithelial  cells,  and  it  is  sometimes  encrusted  with  phosphates. 
This  membrane,  which  is  frequently  formed  in  very  acute  cystitis  and 
in  the  cystitis  of  lying-in  women,  may  invade  the  ureters  and  the  renal 
pelves. 

In  other  cases  the  false  mem])rane  is  made  up  entirely  of  epithelium 
from  fifty  to  one  hundred  times  as  thick  as  the  normal  vesi(^al  epithelium. 

In  gangrenous  cystitis  the  false  membrane  may  be  mixed  with  some 
of  the  constituent  parts  of  the  bladder  membrane  more  or  less  destroyed. 


DISEASES   OF   THE  FEMALE  BLADDER  AND    URETHRA       941 

SymiJtoms.  —  Chronic  cystitis  may  arise  insidiously,  or  may  be  tlie 
sequel  of  acute  cystitis. 

The  symptoms  are  the  same  as  those  of  acute  cystitis,  but  in  a  very 
much  milder  degree.  The  three  cardinal  symptoms  —  frequency  of 
micturition,  painful  micturition  and  pyuria  —  are  present  together.  The 
degree  of  pyuria  is  extremely  variable.  The  pus  is  always  most  abundant 
at  the  commencement  and  finish  of  micturition,  which  indicates  that  its 
chief  source  is  the  mucous  membrane  about  the  neck  of  the  bladder.  It 
differs  much  in  appearance  also  in  different  cases,  being  sometimes 
yellowish  or  greenish ;  sometimes  tenacious,  glairy,  stringy,  and  adherent 
to  the  bottom  of  the  vessel,  like  a  gelatinous  coating  of  greater  or  less 
thickness,  which  cleaves  for  some  seconds  to  the  vessel  on  pouring  off  the 
urine,  and  then  leaves  it  like  a  solid  or  semi-solid  mass. 

The  urine  of  chronic  cystitis  is  alkaline  and,  if  not  actually  am- 
moniacal,  has  a  strong  offensive  odour.  When  the  mucous  membrane  is 
sloughing  the  urine  has  an  odour  characteristically  offensive. 

The  physical  symptoms  of  chronic  cystitis  are  very  slight ;  and  the 
general  good  health  is  maintained  by  many  patients  for  a  long  time,  even 
when  the  quantity  of  muco-pus  is  very  large.  After  a  time,  however, 
they  become  feeble,  lose  flesh,  and  look  pale  and  sallow;  the  skin  dries, 
the  tongue  is  furred,  and  the  digestion  becomes  difficult  or  painful.  In  a 
large  number  of  cases  chronic  pyelo-nephritis  is  gradually  induced ;  in 
others,  an  acute  attack  of  suppuration  throughout  the  higher  urinary 
mucous  track  proves  fatal. 

Diagnosis.  —  Before  making  a  diagnosis  we  should  inquire  as  to  the 
three  coexisting  cardinal  symptoms  ;  namely,  the  frequency  and  the  pain 
of  micturition,  and  the  presence  of  pus  or  muco-pus  in  the  urine.  The 
conditions  with  which  chronic  cystitis  is  most  likely  to  be  confused  are 
neuropathic  states  of  the  bladder,  tuberculosis  of  the  bladder,  and 
pyelo-nephritis. 

In  neuropathic  conditions  pus  is  generally  absent,  though  pain  and 
frequency  of  micturition  may  be  present.  The  bladder  is  not  over- 
sensitive to  the  catheter,  nor  to  vesical  injections.  With  even  the 
smallest  trace  of  pus  we  ought  to  exclude  simple  neuralgia. 

In  pyelo-nephritis  there  is  a  uniform  turbidity  of  the  urine,  and  the 
turbidity  remains  even  after  the  urine  has  had  time  to  deposit;  the  gen- 
eral health  is  impaired,  there  are  feverish  attacks  and,  if  the  bladder 
is  unaffected,  the  urine  is  acid.  If  the  bladder  be  carefully  washed 
out,  the  urine  which  flows  away  through  the  catheter  immediately  after 
is  turbid  with  pus. 

Treatment.  —  The  proper  treatment  of  chronic  cystitis  consists  in 
the  daily  irrigation  of  the  bladder  by  suitable  antiseptic  solutions.  This 
irrigation  must  be  conducted  on  a  careful  and  systematic  plan  ;  not  only 
as  regards  the  details  of  antiseptic  precautions,  but  in  other  respects  as 
well.  It  is  harmful  to  throw  in  too  much  fluid  at  a  time,  or  to  inject  it 
with  too  much  force.  A  tender,  inflamed  bladder  is  irritated,  not  soothed, 
by  such  treatment.     A  soft,  flexible  catheter  of  No.  8  or  9  size  should 


942  SYSTEM   OF  GYNAECOLOGY 

always  be  used  if  possible ;  and  tbe  solution  to  be  injected  should  be  of 
the  temperature  of  the  body,  and  not  too  strongly  impregnated  with 
the  antiseptic  substance.  Only  two,  three,  or  four  ounces  should  be 
injected  ^t  a  time ;  and  then,  after  being  retained  for  a  few  seconds  in 
the  bladder  by  keeping  the  finger  tip  on  the  end  of  the  catheter,  it 
should  be  allowed  to  escape.  This  process  should  be  repeated  till  the 
solution  returns  as  clear,  or  nearly  so,  as  when  it  was  injected. 

The  best  means  of  injecting  the  solution  is  by  a  4  or  6-ounce 
india-rubber  bottle,  fitted  with  a  graduated  nozzle  and  stop-cock  such  as 
are  made  for  this  purpose.  Or,  instead  of  the  india-rubber  bottle,  a  glass 
irrigator,  Avith  a  long  tube  and  nozzle  at  the  end,  can  be  hung  above  the 
patient's  head.  This  is,  perhaps,  a  more  convenient  plan  when  the 
washing  out  is  done  by  the  patient  herself. 

Various  solutions  are  employed,  thus,  acetate  of  lead  (1  or  2  grains 
to  4  ounces  of  water) ;  dilute  nitric  acid  (2  or  3  minims  to  the  ounce)  ; 
dilute  phosphoric  acid  (3  or  4  minims  to  the  ounce) ;  acetic  acid  (4  minims 
to  the  ounce).  These  are  especially  useful  where  there  is  a  great  tendency 
to  phosphatic  encrustation  of  the  bladder.  Sir  Henry  Thompson  recom- 
mends biborate  of  soda  and  glycerine ;  his  formula  is  2  ounces  of  glyce- 
rine, 1  ounce  of  biborate  of  soda,  and  2  ounces  of  water ;  of  this  mixture, 
i  an  ounce  is  added  to  4  ounces  of  water  to  form  the  injection. 

Mr.  Nimn,  as  long  ago  as  1872,  used  and  recommended  a  solution  of 
quinine  sulphate,  in  the  proportion  of  2  grains  to  3  ounces  of  water  in- 
creased to  1  or  2  grains  to  the  ounce.  Another  drug  recommended  by 
Sir  Henry  Thompson  is  nitrate  of  silver  of  the  strength  of  \  to  1  grain  in 
4  ounces,  increased  to  f  grain  to  the  ounce.  Salicylic  acid  (J^  per  cent)  is 
recommended  by  Bryan  of  St.  Louis  for  cleansing  the  bladder  of  tenacious 
muco-pus.  Creolin  in  \  per  cent  solution,  resorcin,  -^-^  per  cent,  and  a 
weak  solution  of  boroglyceride  are  among  the  numerous  substances  which 
may  be  tried.  Instillations,  in  the  form  of  20-30  drops  of  1  in  50 
solution  of  nitrate  of  silver,  or  of  sublimate  solution  (1  in  10,000  increasing 
to  1  to  5000),  are  considered  by  many  French  surgeons  to  be  the  best 
means  of  disinfecting  the  bladder.  Much  benefit,  however,  is  often 
derived  from  an  injection  of  a  drachm  of  iodoform  emulsion  of  the 
strength  of  two  scruples  of  iodoform  to  an  ounce  of  water. 

The  diet  must  be  carefully  regulated  ;  alcohol  is  to  be  forbidden. 

In  women  dilatation  of  the  urethra,  vesico-vaginal  cystotomy,  or 
hypogastric  cystotomy,  may  have  to  be  performed  for  drainage.  Except 
in  cases  where  it  is  reasona])le  to  expect  that  the  drainage  will  not  long 
be  required,  the  latter  operation  is  to  be  preferred.  In  many  cases  of 
cystitis  sanmetto  in  drachm  doses  three  times  a  day  does  excellent  service. 
So  also  does  the  solution  of  parsley  and  kola  seed  mixed  with  coca  and 
saw  Y^almetto  made  by  Bell  and  Company  of  Oxford  Street,  and  named 
by  them  "  lifjuor  petroselini  cum  serenoa  compositus."  Tyson  recom- 
mends santal  oil  to  be  administered  before  meals,  and  an  injection  of 
sodium  salicylate  (a  drachm  to  a  pint)  or  of  alum  solution  to  be  used. 

III.  Tuberculous  Disease  of  the  Bladder.  —  This  is  a  disease  which 


DISEASES    OF   THE  FEMALE   BLADDER  AND    URETHRA       943 

affects  the  period  of  activity  of  the  sexual  organs,  but  is  met  with 
occasionally  in  children  under  four  years  of  age,  and  also  in  extreme  old 
age.     It  is  three  times  more  common  in  men  than  in  women. 

The  general  causes  are  the  same  as  of  tuberculosis  elsewhere.  The 
local  are  to  be  found  in  the  frequency  of  gonorrhoea  and  other  suppura- 
tive discharges,  and  of  infective  cystitis  which,  in  persons  with  this 
proclivity,  are  apt  to  pass  into  tuberculous  disease. 

Morbid  Anatomi/.  — The  bladder  is  generally  small,  shrunken,  thick- 
ened, and  surrounded  by  a  bed  of  sclerosed  libro-fatty  tissues  which 
diminishes  the  risk  of  perforation.  The  mucous  membrane  is  red,  irreg- 
ular, and  fungous-looking,  especially  about  the  trigone  and  about  the 
orifices  of  the  ureters.  Minute  gray  miliary  tubercles  are  occasionally 
seen ;  they  may  be  more  or  less  confluent,  but  do  not  form  the  larger 
cheesy  masses  so  often  met  with  in  the  kidney's,  prostate,  testes,  and 
vesiculae.  Ulceration  is  present  in  the  more  advanced  stages :  the  ulcers 
have  the  characters  of  tuberculous  ulcers  of  other  parts  ;  they  may  be 
small  and  numerous,  or  a  large  ulcer  may  have  arisen  by  the  coalescence 
of  smaller  ones ;  their  depth  varies  from  mere  surface  destruction  to 
actual  perforation.  Though  perforation  is  rare,  it  sometimes  results  in 
fistulous  openings  into  the  rectum,  vagina,  or  perineum ;  or,  after  form- 
ing an  abscess  in  the  cavity  of  Retzius,  an  opening  may  be  established 
through  the  hypogastrium.  Ulceration  may  extend  through  the  urethro- 
vesical  orifice  and  invade  the  urethra.  I  have  met  with  deep  ashy  gray 
tuberculous  ulcers  in  the  urethra  of  girls,  and  also  tuberculous  abscess 
at  the  vesical  end  of  the  ureter. 

It  is  very  rare  for  the  bladder  to  be  the  only  part  of  the  genito- 
urinary apparatus  affected  at  the  time  of  death. 

In  cases  of  pulmonary  phthisis  the  bladder  is  sometimes  found  in  a 
very  early  stage  of  tuberculosis  without  the  appearance  of  any  signs  of 
its  existence  during  life. 

Symptoms. — The  first  symptom  is  frequency  of  micturition  after 
meals  and  at  night.  Then  the  urine  is  slightly  tinted  with  blood  more 
or  less,  and  at  longer  or  shorter  intervals.  Later  still,  pain  occurs  and 
the  urine  is  much  thicker  and  contains  pus ;  then  it  is  that  cystitis 
appears,  and,  as  Tuffier  writes,  the  disease,  which  till  then  was  ''  vesical 
tuberculosis,"  becomes  "  tuberculous  cystitis."  So  it  may  last  for  years 
without  very  greatly  affecting  the  general  health. 

The  functional  symptoms  are  (i.)  freciuency  of  micturition;  (ii.) 
hematuria ;  (iii.)  pain ;  (iv.)  certain  morbid  constituents  of  the  urine. 
Each  of  these  symptoms  must  receive  a  brief  notice.  The  frequency 
of  micturition  comes  on  insidiously,  and  may  exist  for  a  long  time  with- 
out attracting  much  attention.  It  is  due  to  a  slight  congestion  of  the 
mucous  membrane,  and  increases  with  its  cause,  till  at  length  the  need 
to  pass  water  becomes  very  imperious,  and  occurs  every  hour,  or  even 
every  half-hour  ;  and,  in  the  gravest  cases,  it  may  be  almost  continuous 
and  tantamount  to  a  condition  of  "  false  incontinence."  It  is  generally 
worse  at  night  than  in  the  daytime. 


944  SYSTEM  OF  GYNECOLOGY 

Haematuria  is  an  early  symptom  but,  like  the  frequency,  it  may  be 
so  slight  as  to  escape  the  patient's  observation  for  a  time.  It  is  com- 
pared to  the  hsemoptj'sis  of  pulmonary  tuberculosis  and,  like  the  fre- 
quency of  micturition,  is  due  at  first  to  active  congestion  of  the  mucous 
membrane ;  later,  however,  there  may  be  an  actual  haemorrhage  from 
the  ulcerated  surface.  As  an  early  symptom  it  is  spontaneous  and  slight, 
the  urine  being  faintly  pink  or  rose-tinted  throughout ;  but  a  few  drops 
of  pure  blood  may  issue  at  the  end  of  micturition.  As  it  comes,  so  it 
goes,  without  obvious  cause ;  it  is  thus  unlike  the  hsematuria  of  calculus, 
but  like  the  haematuria  of  tumour.  In  one  respect,  however,  it  differs  ; 
the  bleeding  of  tumours  is  free  and  abundant,  the  haematuria  of  tuber- 
culosis is  slight.  In  the  middle  stages  of  the  disease  the  haematuria  may 
cease ;  but  in  the  later,  if  it  should  recur,  it  may  be  very  considerable. 

Fain  is  an  indication  of  cj'stitis.  It  is  often  brought  on  by  sounding, 
after  which  the  three  cardinal  symptoms  of  cystitis  may  appear ;  namely, 
frequency  of  micturition,  pain,  and  pus.  In  some  cases  the  pain  of  tuber- 
cular cystitis  is  by  no  means  severe,  and  certainly  not  incompatible  with 
the  ordinary  pursuits  of  life.  In  others  it  is  frequent  and  intense,  or 
even  continuous  and  agonising;  it  precedes,  accompanies,  and  follows 
micturition;  and  as  the  frequency  of  micturition  is  increased  by  the 
cystitis,  there  may  be  no  cessation  day  or  night  of  the  terrible  sufferings. 

Sometimes  the  pains  are  accompanied  by  spasm  of  the  membranous 
urethra,  and  thus  temporary  retention  adds  greatly  to  the  distress.  In 
the  most  advanced  stage,  especially  if  the  neck  of  the  bladder  have  been 
partially  destroyed  by  ulceration,  there  may  be  incontinence  of  urine. 

Polypoid  excrescences  sometimes  occur  about  the  urinary  meatus  and 
urethra  of  women  affected  by  tuberculous  disease  of  the  bladder. 

Tlis  Urine. — With  the  onset  of  the  frequency  of  micturition  there 
is  increase  in  quantity  to  three  or  four  pints,  but  the  urine  remains  clear; 
later  it  may  become  purulent  with  the  cystitis.  Tubercle  bacilli  are 
found  in  the  first  stage,  but  not  when  there  is  much  pus. 

Diagnosis.  —  Vesical  tuberculosis  ought  to  be  suspected  in  any  case 
in  which  frequency  of  micturition,  with  slight  haematuria,  occurs  between 
the  ages  of  fourteen  and  forty -five ;  especially  if  the  patient  have  a  tuber- 
culous aspect  or  family  history.  If  cystitis  occur,  and  the  presence  of 
tubercle  be  ascertained  in  the  lungs,  generative  organs,  or  other  parts, 
the  diagnosis  becomes  pretty  certain. 

Some  nervous  diseases  may  simulate  tuberculosis  of  the  bladder; 
but  there  will  be  other  evidence  of  these,  and  the  pains  will  precede 
the  evidence  of  cystitis. 

Vesical  calculus  yjresents  a  different  form  of  haemorrhage;  and  the 
symptoms  are  allayed  by  rest  in  the  horizontal  position. 

Vesical  tumours  cause  more  copious  haemorrhage ;  and  less  marked 
frequency  of  micturition. 

From  cystitis  due  to  other  causes,  tuberculous  cystitis  is  distinguished 
y)y  the  onset  and  course  of  the  disease,  and  l)y  the  result  of  examination 
of  the  urine.     There  may  be  some  difficulty  in  making  a  diagnosis  in 


DISEASES   OF   THE  FEMALE   BLADDER  AND    URETILRA       945 


those  cases  in  which  the  tuberculosis  has  followed  an  old  gonorrhea  or 
a  deep-seated  urethral  discharge. 

From  tuberculosis  of  the  kidneys  and  ureters  the  diagnosis  is  often 
very  difficult.  The  disease  in  the  bladder  progresses  very  much  more 
slowly  than  in  the  kidneys.  In  cystitis  the  urine  is  at  first,  and  for  a 
long  while,  much  less  charged  with  pus,  and  that  which  is  first  passed 
contains  more  than  the  rest  of  the  urine ;  and  there  are  not  the  digestive 
disturbances,  the  dry  tongue,  and  the  rapid  emaciation,  which  are  pro- 
duced by  the  renal  disease. 

In  women  the  diagnosis  is  more  difficult  than  in  men.  Hsematuria, 
rather  than  frequency  of  micturition,  is  likely  to  be  the  first  symptom 
noticed;  the  sexual  organs  do  not  give  corroborative  evidence,  and 
cystitis  is  more  often  met  with  in  women  without  obvious  cause.  In- 
oculation experiments  and  the  inefficacy  of  general  treatment  will  indi- 
cate the  diagnosis.  And,  in  doubtful  cases  of  urinary  tuberculosis,  the 
thermometer  seldom  fails  to  assist  us,  as  the  temperature  nearly  always 
rises. 

Prognosis.  —  The  course  of  tuberculosis  of  the  bladder  is  a  slow  one  ; 
acute  attacks  are  frequently  followed  by  periods  of  amelioration,  and  the 
disease  may  last  some  years.  If  the  tuberculous  process  itself  do  not 
reach  the  kidneys,  the  end  is  generally  brought  about  by  pyelo-nephritis 
of  the  common  suppurative  form.  Occasionally  tuberculous  peritonitis, 
acute  phthisis  pulmonalis,  or  acute  general  tuberculosis,  is  the  immediate 
cause  of  death.  Cold  abscesses  about  the  bladder,  and  the  continued 
discharges  from  the  resulting  fistulas,  help  to  wear  out  the  patient. 

Treatment.  —  Surgical  treatment  based  on  the  radical  extermination  of 
the  microbic  cause  of  the  disease  has  up  to  the  present  been  disappointing. 

The  general  and  medicinal  treatment  in  the  early  stages  of  the  disease 
—  as  regards  climate,  diet,  clothing,  medicines,  dry  frictions,  sulphur  or 
salt  baths,  sea  voyages,  visits  to  the  thermal  springs,  arsenical  prepara- 
tions, creasote,  cod  liver  oil  —  are  the  same  as  in  pulmonar}^  phthisis. 
Articles  ought  especially  to  be  avoided  which,  through  the  urine,  irritate 
the  bladder ;  such  are  all  kinds  of  alcoholic  stimulants,  curries,  spices, 
nux  vomica,  juniper,  and  so  forth.  Thus  it  is  to  medicinal,  rather  than 
to  surgical  means,  that  the  patient  should  look  for  benefit. 

Mercurial  ''  instillations,"  however,  render  great  service.  These  in- 
stillations consist  of  the  injection  into  the  bladder  of  from  10  to  40  drops 
of  sublimate  solution,  varying  in  strength  from  1  in  5000  to  1  in  1000. 
It  is  claimed  for  this  treatment  that  it  acts  not  onl}^  as  a  medicinal 
remedy  to  relieve  pain,  but  as  a  germicide  to  kill  the  microbes;  and 
that  its  value  is  perceived  in  early  stages  by  its  success  in  relieving 
frequency  of  micturition. 

If  these  means  fail,  and  the  bladder  becomes  very  irritable  and  the 
pains  severe,  morphia  must  be  liberally  administered;  even  if  required 
to  the  extent  of  several  grains  in  the  twenty-four  hours.  Of  course  the 
dose  at  first  must  be  small,  and  the  increase  must  be  cautious  and 
gradual ;  but  very  large  doses  will  ultimately  be  tolerated. 

3p 


946  SYSTEM   OF  GYNAECOLOGY 

Cystotomy  should  be  the  last  resource,  and  onl}^  employed  to  relieve 
frequent  and  severe  pain  and  irritability  of  bladder.  The  operation 
Avhich  hitherto  seems  to  have  afforded  most  relief  has  been  supra-pubic 
drainage  of  the  bladder,  followed  in  some  cases  by  the  application  of 
nitrate  of  silver,  or  chlorine  of  zinc,  or  sublimate  solution  (1  in  5000)  to 
the  seat  of  the  disease. 

Injuries  to  Bladder.  —  Rupture.  —  Ruptures  of  the  bladder  are  of 
three  kinds  :  traumatic ;  idiopathic  ;  and  pathological. 

Etiology.  —  The  traumatic  are  caused  either  by  violence  from  with- 
out, or  by  violent  muscular  efforts  on  the  part  of  the  patient  herself : 
the  pathological  result  from  ulceration,  sloughing,  thinning,  and  sac- 
culation of  the  parietes;  the  idiopathic  result  from  the  spontaneous 
yielding  of  the  distended  bladder,  independently  of  any  form  of  vio- 
lence, or  of  previous  ulceration,  sloughing,  or  tunicary  hernise. 

In  rupture  during  labour  the  distended  bladder  is  compressed  between 
two  strong  muscular  forces  ;  namely,  the  contracting  abdominal  parietes 
and  the  contracting  and  enlarged  uterus.  In  rupture  during  the  strug- 
gles under  anaesthesia,  and  during  powerful  muscular  efforts,  such  as 
lifting  or  pushing,  the  bladder  wall  is  passive  and  the  rupturing  force 
is  in  the  abdominal  parietes. 

Traumatic  ruptures  form  the  bulk  of  the  intraperitoneal  cases  and 
of  those  which  are  partly  intraperitoneal  and  partly  extraperitoneal. 

True  idiopathic  ruptures,  or  those  which  occur  when  there  is  no 
disease,  and  where  no  violence  was  used,  are  very  rare.  In  most  cases  of 
rupture  during  urinary  retention  the  bladder  gives  way  under  forcible 
muscular  efforts  as  explained  above;  so  likewise  in  cases  of  rupture  dur- 
ing heavy  lifting,  parturition,  and  muscular  spasms.  Thus  this  class 
is  restricted  to  certain  cases  of  rupture  from  simple  over-distension  by  tu- 
mours, retroversion  of  the  gravid  uterus,  and  the  like ;  to  spontaneous 
ruptvire  during  alcoholism,  erysipelas,  fever,  hysteria  (Dr.  J.  B.  Wil- 
mont's  case),  and  other  serious  illnesses  ;  and  finally  to  the  foetus  in  utero. 

In  pathological  rupture  the  bladdei-,  weakened  at  certain  spots  by 
ulceration  or  tunicary  hernise,  gives  way  under  distension ;  or  it  sloughs 
as  the  result  of  pressure  or  inflammation.  Rivington  collected  9  cases 
of  intraperitoneal  rupture  from  retroversion  of  the  gravid  uterus ;  2  of 
intraperitoneal  rupture  from  extra-uterine  fcjetation ;  and  7  cases  (3  in- 
traperitoneal, 3  extraperitoneal,  and  1  doubtful)  due  to  ulcc^-ation. 

Krukenberg,  who  has  collected  10  cases  of  rupture  from  retroversion 
of  the  gravid  womb,  and  added  1  observed  by  himself,  considers  the 
pathology  of  rupture  of  the  bladder  and  gangrene  of  the  vesical  wall  to 
be  identical.  In  some  cases  protective  adhesions  on  the  peritoneal 
surface  are  formed  during  the  progress  of  the  gangrenous  inflammation 
of  the  coats  of  the  Ijladder,  and  then  the  gaugi'onous  parts  may  be  cast 
off  entire  or  broken  up;  otherwise,  perforaticui  attends  the  separation  of 
the  slough,  even  without  over-distension  of  the  bladder.  Rupture  may 
also  take  place  suddenly  from  over-distension  before  the  separation  of  any 


DISEASES   OF  THE  FEMALE  BLADDER  AND    URETHRA       947 

slough ;  or  may  result  from  efforts,  even  the  most  gentle  and  careful,  to 
replace  the  uterus.  Krukenberg  adds  that  when  retention  of  urine 
persists  for  ten  days  or  longer,  either  gangrene  or  rupture  of  the  bladder 
may  occur  ;  but  rupture  more  frequently.  He  also  gives  the  warning 
that,  if  gangrenous  portions  of  the  vesical  wall  have  been  cast  off,  no 
attempt  should  be  nuide  to  replace  the  uterus ;  but  that  abortion  ought 
to  be  induced. 

The  pressure  of  a  retroverted  gravid  uterus  has  caused  gangrene  of 
the  walls  of  the  bladder  in  several  instances. 

Tlie  Situation  of  the  Rent.  —  The  posterior  surface  of  the  bladder  is 
the  common  site,  and  the  more  or  less  vertical  line  the  common  direction 
of  the  simple  intraperitoneal  traumatic  rupture.  This  rule,  however,  is 
subject  to  many  exceptions.  In  spontaneous  ruptures  the  rent  is  com- 
monly behind,  and  is  usually  small  and  round. 

The  quantity  of  urine  effused  into  the  peritoneal  cavity  varies,  and 
increases  as  life  is  prolonged.  If  death  occur  Avithin  three  days  a  large 
quantity  may  be  present  without  any  signs  of  peritonitis.  Surgical 
casualties  in  operations  on  the  abdomen  have  repeatedly  shown  that 
healthy  urine  is  harmless  to  the  peritoneum,  especially  if  it  can  find  an 
exit ;  and,  moreover,  that  it  may  be  rapidly  absorbed.  Experiments,  too, 
show  the  small  quantity  of  urine  injected  into  the  peritoneum  is  inoffen- 
sive ;  that  injections  may  be  repeated  with  impunity  ;  but  that  a  persistent 
effusion  excites  peritonitis  (Tuffier).  On  the  other  hand,  when  life  has 
been  prolonged,  and  septic  elements  have  been  introduced  by  the  catheter, 
or  have  established  themselves  about  the  inflamed  and  contused  edges 
of  the  wound,  the  evidences  of  peritonitis  will  be  well  marked. 

Diagnosis.  —  The  most  certain  evidence  of  intraperitoneal  rupture  is 
the  entrance  of  a  catheter  into  the  peritoneal  cavity  through  the  rent 
in  the  empty  bladder.  In  extraperitoneal  rupture  signs  of  urinary  extrav- 
asation may  appear  soon ;  but  in  some  cases  they  are  not  apparent  for 
many  hours. 

The  injection  of  a  warm  antiseptic  solution  into  the  bladder  may  be 
of  great  use  in  diagnosis ;  if  the  bladder  is  sound,  the  usual  swelling  of 
a  distended  bladder  will  be  formed,  and  will  disappear  on  the  return  of 
the  fluid  through  the  catheter. 

Prognosis.  —  This  is  most  grave.  Walsham  has  collected  28  cases 
of  intraperitoneal  rupture  of  the  bladder  treated  by  sutures  since  1888 ; 
of  this  number  11  recovered  and  17  died.  In  only  1  out  of  the  11 
successful  cases  was  peritonitis  present  at  the  time  of  the  operation ; 
whereas  in  8,  and  probably  in  9,  out  of  the  17  unsuccessful  cases 
peritonitis  had  set  in  before  the  operation  was  commenced.  The  causes 
of  death  in  the  8  cases  in  Avhich  peritonitis  did  not  precede  the  opera- 
tion were  shock  or  haemorrhage,  or  both  combined,  in  5;  peritonitis 
from  leakage  in  2,  if  not  in  3.  In  4  out  of  17  cases  the  rent  had  not 
been  securely  closed  and  leakage  occurred. 

Treatment.  —  The  first  thing  in  many  cases  will  be  to  attend  to 
the  condition  of  extreme  shock  by  the  application  of  warmth,  gentle 


948  SYSTEM  OF  GYNECOLOGY 

stimulation,  and  the  like,  requisite  in  all  sucli  cases.  Next  must  be 
the  prompt  local  treatment  to  prevent  the  further  escape  of  urine  into 
the  peritoneum  or  pelvic  cellular  tissue  by  providing  a  ready  exit  for  the 
urine  as  it  reaches  the  bladder  by  catheter  ;  and  by  closing  the  wound 
in  the  bladder  by  sutures  when  this  is  possible.  And  here  everything 
depends  upon  an  early  and  an  accurate  diagnosis.  If  the  case  be  one 
of  intraperitoneal  rupture  no  time  is  to  be  lost  (where  sufficient  assist- 
ance and  proper  convenience  can  be  obtained  for  the  operation)  in 
performing  laparotomy,  clearing  out  the  urine  and  blood  from  the 
peritoneal  cavity,  and  securely  suturing  the  opening  in  the  bladder  wall. 

When  the  surgeon  is  single-handed,  and  cannot  get  assistants  or 
appliances  within  twenty -four  hours,  let  him  employ  antiseptic  drainage 
of  the  bladder  from  the  outset,  and  reduce  to  a  small  limit  the  quantity 
of  fluid  given  to  the  patient  for  the  first  three  or  four  days.  Para- 
centesis of  the  abdomen  or  recto-vesical  pouch  need  hardly,  if  ever,  be 
performed. 

In  extraperitoneal  ruptures  a  catheter  should  be  retained  in  the 
bladder  with  the  most  rigid  antiseptic  precautions,  taking  care  that  the 
instrument  is  large,  and  that  the  urine  is  run  off  into  a  vessel,  containing 
an  antiseptic  solution,  placed  beneath  the  bed. 

Vesico-vaginal  Fistula.  —  A  communication  between  the  bladder  and 
either  the  uterus  or  vagina,  so  as  to  admit  of  the  more  or  less  continuous 
escape  of  urine,  is  a  condition  productive  of  extreme  distress.  The  size 
of  the  opening  varies  from  that  of  a  pin's  point  to  a  diameter  of  an  inch 
or  more.  When  recent  the  aperture  is  usually  at  its  largest,  diminishing 
later  by  cicatricial  contraction.  At  the  same  time  the  bladder  shrinks, 
and  the  walls  are  contracted  and  thickened.  Sometimes  the  mucous 
membrane  of  the  bladder  can  be  seen  to  protrude  through  the  opening 
in  the  vesico-vaginal  septum.  The  urethra  is  often  considerably  nar- 
rowed, as  a  result  of  disuse,  and  the  edges  of  the  fistula  are  thickened 
and  sometimes  held  apart  by  cicatricial  fibrous  tissue. 

Etiology.  —  By  far  the  commonest  cause  of  communication  between 
bladder  and  vagina  is  cancer  of  the  cervix  uteri  extending  to  the 
septum,  and  causing  destruction  of  it.  When  the  disease  has  reached 
this  stage  it  is  beyond  the  power  of  remedies;  it  only  remains  to 
adopt  measures  for  soaking  up  the  escaping  urine  and  protecting  the 
skin.  Fistula  developing  in  connection  with  parturition  belongs  to  a 
different  category.  It  results  either  from  direct  laceration  or,  more  often, 
from  sloughing,  following  continued  pressure  of  the  foetus  within  the 
pelvis.  Other  less  frequent  causes  are  necrosis  attending  diphtheritic 
inflammation  of  the  bladder,  and  ulceration  produced  by  the  long  con- 
tinued pressure  of  a  pessary  in  the  vagina. 

tSymptoms.  —  These  are  chiefly  due  to  the  escape  of  urine  by  the 
vagina  and  the  consequent  irritation  of  the  skin.  P)esides  these,  how- 
ever, amenorrhrtia,  sterility,  and  constipation  are  usually  present,  with 
great  impairment  of  the  general  health. 

The  diagnosis  is  generally  easy.     Where  the  apertures  are  small  or 


DISEASES   OF   THE   FEMALE  BLADDER  AND    URETHRA       949 

concsaled  the  bladder  should  be  distended  with  milk  oi-  some  coloured 
fluid,  while  the  vagina  is  carefully  inspected  by  means  of  a  speculum. 

Treatment  consists  in  paring  and  suturing  the  edges,  after  fully 
exposing  the  site  of  the  lesion,  and  in  draining  the  bladder  till  they 
have  united,     \yide  article  on  Plastic  Operations,  p.  772.] 

Foreign  Bodies.  —  Foreign  bodies  gain  access  to  the  cavity  of  the 
bladder  (i.)  through  the  urethra;  (ii.)  when  forced  through  its  walls  by 
injury  ;  (iii.)  by  means  of  ulceration,  or  the  formation  of  a  fistula,  which 
is  most  often  of  cancerous  origin. 

In  the  first  category,  by  far  the  greater  niimber  are  substances  intro- 
duced by  patients  either  to  allay  itching  or  for  some  aimless  or  sensual 
purpose ;  the  variety  of  things  which  have  been  so  introduced  is  almost 
endless.  In  the  second  are  found  bullets,  pieces  of  bone  or  of  raiment, 
or  buttons.  Foreign  bodies  which  ulcerate  into  the  bladder,  or  find  their 
way  along  fistulous  tracts,  come  either  from  the  vagina,  the  rectum,  or 
the  higher  intestines,  from  extra-uterine  gestation  cysts,  from  dermoid 
cysts,  or  from  abscesses  in  the  pelvic  cellular  tissue. 

In  this  way  vaginal  pessaries  have  passed  through  the  vesico-A^aginal 
septum ;  pieces  of  horn,  coins,  faecal  matter,  and  intestinal  worms  have 
entered  from  the  bowel ;  fragments  of  a  foetus  in  extra-uterine  gesta- 
tion ;  hair  and  teeth  from  dermoid  cysts ;  hydatids ;  and  pus  and  bone 
from  pelvic  abscesses. 

From  the  observations  of  Guyon  and  Henriet  it  appears  that,  Avhen 
once  fairly  within  the  cavity  of  the  bladder,  foreign  bodies  occupy  most 
frequently  a  transverse  position  between  the  summit  and  the  neck  of  the 
bladder,  and  rather  nearer  the  neck.  In  the  empty  bladder  this  posi- 
tion is  more  constant  than  in  the  full  bladder ;  in  the  empty  bladder  it  is 
the  only  position  which  bodies  not  longer  than  ten  centimetres  can  take. 
Smaller  bodies  can  occupy  any  position  in  the  distended  bladder ;  but  in 
the  empty,  or  nearly  empty  organ,  they  assume  the  line  of  the  transverse 
diameter.  A  body  of  twelve  centimetres  in  length  takes  a  vertical  X)Osi- 
tion,  or,  if  one  of  its  ends  is  buttressed  near  the  neck,  it  may  lie  oblirjuely. 
Light  bodies  float;  hollow  ones,  such  as  a  piece  of  tubing  or  of  a  catheter, 
generally  lie  in  the  base  of  the  bladder.  Some  becon^e  disintegrated  and 
are  passed  in  particles,  perhaps  even  without  the  patient's  knowledge. 

Foreign  bodies,  when  in  the  bladder,  may  remain  entirely  quiescent, 
or  they  may  excite  cystitis ;  after  a  time  they  may  cause  ulceration  and 
perforation,  and,  giving  rise  to  a  perivesical  abscess,  may  escape  by  the 
direction  through  Avhich  the  abscess  is  either  opened  or  spontaneously 
discharged.  Or  the  foreign  body,  having  penetrated  the  vesical  wall, 
may  remain  partly  within  the  bladder  and  partly  within  the  peritoneal 
cavity.  The  foreign  bodies  become  encrusted  Avith  phosphates,  and  are 
then  often  the  nucleus  of  a  stone.  This  deposition  begins,  in  some  in- 
stances even  within  twenty-four  hours,  u])on  the  largest  part  of  the 
foreign  body  and  ])ro(>ceds  towards  the  extremities ;  these  parts,  however, 
never  become  encrusted. 


950  SYSTEM   OF  GYNECOLOGY 

Symi^toms  may  be  entirely  absent ;  but,  as  in  the  case  of  calculus,  the 
rule  is  for  the  patient  to  have  pain  and  frequent  micturition,  and  possibly 
to  discharge  a  little  blood  at  the  end  of  micturition.  Hair  and  other 
rough  or  sharp  bodies  are  apt  to  excite  cystitis  with  its  attendant 
cardinal  symptoms. 

If  the  foreign  body  penetrate  the  cellular  tissue  and  form  an  abscess 
in  the  pelvis,  the  local  and  constitutional  signs  of  inflammation  and 
suppuration  ensue.  If  they  penetrate  into  the  rectum  there  will  proba- 
bly be  rectal  tenesmus  ;  if  into  the  peritoneum  or  small  intestines,  signs 
of  peritonitis  will  most  likely  occur. 

Diagnosis.  —  When  the  foreign  body  has  been  introduced  by  the 
patient  the  readiest  road  to  a  correct  knowledge  of  the  case  is  the  frank 
admission  of  the  patient ;  but  she  often  denies  any  knowledge  of  what 
she  herself  has  done. 

In  surgical  accidents,  such  as  catheters  breaking  off  in  the  bladder, 
there  is  no  room  for  doubt.  In  traumatic  cases  there  is  the  history  of 
the  injury  and  the  presence  of  a  wound  or  scar.  In  perforation  of  the 
vaginal  septum,  there  is  the  history  of  local  pain,  and  probably  the 
existence  of  the  ulcerated  aperture  or  its  scar.  When  the  foreign  body 
has  passed  through  from  the  intestinal  tract  there  may  be,  or  may  have 
been,  the  escape  of  gas,  faeces,  or  ingesta  along  the  urethra. 

In  the  case  of  hysterical  women,  however,  it  is  necessary  to  bear  in 
mind  that  all  sorts  of  things  are  designedly  mixed  with  the  urine. 

Hydatids  passed  with  the  urine  will  give  the  clue  to,  their  presence 
in  the  bladder. 

It  is  of  great  importance,  especially  with  a  view  to  its  extraction,  to 
learn,  if  possible,  the  shape  and  size  of  the  foreign  body,  and  the  length 
of  time  it  has  been  lodged  in  the  organ.  In  all  cases  of  doubt  the  sur- 
geon should  examine  the  bladder  (a)  by  the  finger  in  the  rectum,  in  the 
vagina,  or  passed  into  the  bladder  through  the  dilated  urethra,  (b)  by 
sounding,  and  (c)  by  the  cystoscope. 

Treatment.  —  If  the  foreign  body  has  been  recently  introduced,  and 
it  is  soft  and  pliable,  like  a  piece  of  tube  or  gum-elastic  catheter,  it  can 
readily  be  extracted  by  the  lithotrite,  no  matter  how  it  is  seized  by  the 
blades  of  the  instrument.  Hard,  rounded  bodies  can  also  be  easily 
extracted  by  the  lithotrite ;  either  with  or  without  breaking  them  into 
fragments.  Elongated  substances,  whether  blunt  or  sharp,  give  great 
trouble  because  of  the  difficulty  of  catching  them  in  their  long  axis. 
The  cystoscope  will  often  be  of  great  value  in  this  respect  by  informing 
us  of  the  direction  in  which  the  body  lies.  Some  l)odies,  such  as  a 
hairpin,  for  example,  may  be  luckily  caught  at  their  curved  ends  and 
withdrawn  by  means  of  a  blunt  hook  at  the  end  of  a  flexible  stem. 

When  the  foreign  body  has  become  encrusted  with  calculous  matter, 
some  advise  that  the  deposit  should  be  detached  by  the  lithotrite,  and  the 
foreign  body  extracted  in  the  same  manner  as  if  it  had  only  recently  been 
introduced  ;  and  tha,t  the  calculous  matter  should  then  be  removed  as  in 
litholapaxy.     This,  however,  is  l)y  no  means  always  easy ;  and  sometimes 


DISEASES   OF   THE  FEMALE  BLADDER  AND   URETLIRA       951 

it  is  quite  impossible  to  detach  the  calculous  matter  thoroughly  from  the 
foreign  body:  on  the  whole,  it  is  the  better  practice  in  most  cases  cf 
calculous  formation  to  remove  the  foreign  body  by  operation,  without 
attempting  the  double  procedure  with  the  lithotrite  and  extraction 
instrument. 

Bodies,  such  as  twigs  of  trees,  are  very  dangerous,  as  they  are  liable 
to  be  broken,  and  their  leaves  or  broken  particles  may  cling  to,  or  stick 
into  the  mucous  membrane,  whence  they  cannot  be  dislodged  either  by 
instruments  or  irrigation.  Cystitis  is  very  apt  to  arise  and  to  be  followed 
by  ascending  suppuration  and  death  from  pyelo-nephritis.  This  compli- 
cation, of  course,  may  occur  in  the  case  of  other  foreign  bodies. 

In  women  it  will  be  rarely  necessary  to  resort  to  any  cutting  opera- 
tion, as  the  dilatability  of  the  female  urethra  allows  the  extraction  of 
most  foreign  bodies  which  can  enter  the  bladder. 

After  extraction  the  treatment  is  the  same  as  after  extracting  an 
ordinary  calculus,  and  will  vary  according  to  the  presence  or  absence  of 
cystitis. 

Neoplasms.  — New  growths  of  the  bladder  present  numerous  histo- 
logical varieties  and  considerable  clinical  differences.  Clinically,  some 
are  benign  and  others  malignant ;  histologically,  the  benign  comprise 
papilloma,  myxoma,  fibroma,  and  myoma.  The  malignant  are  carcinoma 
and  sarcoma. 

The  following  table  shows  the  relative  frequency  of  malignant  and 
non-malignant  new  growths  in  the  bladder :  — 


Cancer 
Sarcoma 
Fibroma 
Papilloma  (villous) 


There  are  some  characters  common  to  all  bladder  tumours.  Their 
usual  situation  is  about  the  trigone  and  the  orifice  of  the  uterus.  Benign 
tumours  are  generally  rounded,  often  polypoid  or  tufted ;  the  malignant 
tumours  are  more  generally  spread  out. 

Their  size  varies  from  that  of  a  cherry  to  that  of  an  ^z%\  larger 
growths  are  rare,  and  are  generally  myoma. 

Cancerous  and  sarcomatous  tumours  are  not  unfrequentl^'  multiple, 
the  masses  being  apparently  independent  of  one  another. 

Tumours  may  be  embedded  in  the  vesical  wall,  or  sessile,  or  pedun- 
culated on  its  surface ;  or  they  may  infiltrate  it. 

Papilloma  is  of  two  kinds,  the  fimbriated  or  "  villous  polypi,"  and 
the  fibro-papillomas,  or  "papillary  tumours."  In  the  villous  polypi  the 
stalk  sends  off  numeroiis  branches  and  sub-branches  of  polypi,  which 
consist  of  a  capillary  vessel  covered  hy  a  basement  membrane  and  a 


Total. 

Males. 

Femali 

59 

43 

16 

6 

5 

1 

2 

1 

1 

23 

21 

2 

90 

70 

20 

952  SYSTEM   OF  GYNECOLOGY 

more  or  less  thick  layer  of  epithelium ;  in  the  papillary  tumours  the 
stroma  is  compact  and  has  a  dense  fibrous  or  muscular  structure,  amongst 
vrliieh  may  be  found  embryonal  cells  and  leucocytes.  The  villous  polypi 
are  very  frequently  multiple,  and  form  tufts  or  feathery  bunches  of  vary- 
ing lengths  more  or  less  spread  over  the  mucous  surface ;  these  float 
in  the  urine.  When  very  long  their  extremities  are  often  carried  into 
the  urethro-vesical  orifice  during  micturition  and  are  there  nipped  by 
the  sphincter :  this  is  a  cause  of  considerable  suffering.  There  is  no 
infiltration  of  the  vesical  wall  about  their  points  of  attachment.  The 
papillary  tumour  or  '■'■  fibro-papilloma  "  may  be  single  or  multiple ;  it  is 
generally  rounded  in  shape,  and  of  the  size  of  a  pea,  a  cherry,  or  a  wal- 
nut. It  is  more  often  sessile  than  pedunculated ;  its  surface  is  villous, 
but  its  consistence  is  firm. 

Myxoma  is  in  reality  a  "  fibro-papilloma,"  or  a  fibroma,  the  cell  por- 
tions of  which  have  undergone  a  mucoid  degeneration.  These  tumours 
are  soft  in  texture,  grow  rapidly,  and  are  met  with  most  frequently  in 
young  children.  They  are  probably  often  congenital,  frequently  multi- 
ple and  pedunculated ;  their  common  situation  is  near  the  neck  of  the 
bladder,  and  they  may  extend  into  the  urethra. 

Fibroma  originates  in  the  deep  mucosa  or  in  the  muscular  layer,  and 
is  covered  by  normal  epithelium.  Like  myxoma,  these  growths  are 
pedunculated ;  but  they  occur  in  adults,  and  have  not  yet  been  found  in 
children.     They  are  very  rare. 

Myomas  are  rare ;  two  cases  reported  by  Belfield  show  indisputably 
that  they  may  arise  from  the  vesical  wall.  They  occur  as  nodules  en- 
capsuled  in  the  submucosa ;  they  may  be  composed  either  of  unstriped 
muscular  fibres  (myoma),  or  of  this  mixed  with  fibrous  tissue. 

Sarcoma  is  comparatively  rare,  but  its  rarity  has  probably  been 
greatly  exaggerated. 

Carcinoma. — Two  varieties  are  met  with:  (i.)  epithelioma,  that  is, 
squamous-celled  carcinoma,  or  cylindroma;  and  (ii.)  glandular-celled 
carcinoma,  either  encephaloid  or  scirrhous.  Colloid  degeneration  of 
the  glandular-celled  carcinoma  may  occur,  but  is  rare. 

Secondary  carcinoma  is  more  frequent  than  primary,  and  may  be 
consecutive  to  cancer  of  the  rectum,  vagina,  or  uterus.  These  tumours 
form  prominent,  irregularly  rounded  swellings,  widely  attached,  and 
infiltrating  the  vesical  coats  more  or  less  deeply.  Their  surface  is 
gi-anular,  and  in  the  later  stages  is  ulcerated;  occasionally  they  present 
gaping  ulcers  with  raised  and  indurated  walls.  They  are  hard,  but 
friable;  and  therein  differ  from  the  softer  but  little  friable  fibro-papil- 
lomas.  They  are  often  multiple,  and  are  most  common  in  the  trigone 
or  Vjase  of  the  bladder.  They  develop  slowly,  seldom  ulcerate  early,  and 
cause  death  before  they  attain  any  great  size;  often  before  they  are 
followed  by  secondary  growths  in  distant  oi-gans. 

Some  tumoui's  which  have  been  exceptionally  found  in  the  bladder 
are  adenoma,  angeioma,  serous  cystoma,  and  dermoid  cystoma.  The  latter 
is  probably  (hie  either  to  an  abnormal  developuH^nt  of  the  bladder  wall, 


DISEASES   OF   THE  FEMALE  BLADDER  AND    URETHRA       953 

by  which  a  portion  of  the  epiblast  fills  in  a  deficiency,  or  they  are  peri- 
vesical in  origin. 

Mticons  iwbjpi,  having  a  texture  resembling  that  of  ordinary  nasal 
polypus,  except  that  the  epithelial  covering  is  squamous  instead  of 
ciliated,  have  been  found  in  the  bladders  of  children  under  two  years 
of  age,  as  well  as  in  adults.  In  the  early  stage  they  may  not  give  rise 
to  any  symptoms ;  later  they  may  simulate  vesical  calculus,  and  growing 
to  a  considerable  size  project  even  beyond  the  urethra,  or  distend  the 
bladder  to  the  level  of  the  umbilicus. 

Bilharzia  hcematobia  sometimes  causes  masses  of  fungating  exuda- 
tion of  considerable  size  in  the  bladder.  It  is  not  an  uncommon  cause  of 
haematuria  in  the  Nile  district.    [Art.  "  Bilharzia  "  in  Syst.  of  Med.  vol.  ii.] 

Pathological  complications  of  bladder  tumours  are:  (i.)  local  thicken- 
ing of  the  bladder  walls  due  to  hypertrophy  of  muscular  and  interstitial 
tissue ;  (ii.)  hydronephrosis ;  (iii.)  calcareous  deposit  on  the  surface  of 
the  tumour ;  (iv.)  occasionally  a  phosphatic  calculus  free  in  the  bladder, 
the  result  of  a  cystitis  provoked  by  the  growth,  possibly  a  portion 
of  the  growth  broken  away  from  the  rest  may  form  its  nucleus ; 
(v.)  suppurative  pyelo-nephritis  with  or  without  distension  of  the  kidne}-. 

Spnjytoms.  —  Bladder  tumours  are  met  Avith  at  all  ages,  the  sarcomas 
and  myxomas  in  children ;  cancer  between  forty  and  sixty.  They  are 
much  more  common  in  men  than  in  women. 

A  small  number  of  tumours  of  the  bladder  are  quite  unsuspected 
during  life,  as  large  calculi  have  been  found  as  a  surprise  in  autopsies. 
But  as  a  rule  their  presence  is  made  only  too  apparent  by  haemor- 
rhage, pain,  frequency  of  micturition,  and,  not  unfrequently,  by  the 
presence  of  a  swelling  felt  either  through  the  vagina  or  through  the 
anterior  abdominal  wall.  Haematuria  is  by  far  the  most  constant 
symptom ;  in  some  cases  it  is  the  only  one,  and  sometimes  is  alone  the 
cause  of  death.  It  is  nearly  always  the  first  symptom  complained  of,  and 
the  one  which  brings  the  patient  to  his  doctor.  Its  onset,  its  course,  and 
its  abundance  are  characteristic  of  tumour.  It  comes  on  spontaneously 
without  injury,  fatigue,  or  even  movement ;  and  it  causes  no  difficulty  in 
micturition  unless  a  clot  for  a  while  obstruct  the  urethra.  It  may  be 
excited  by  catheterism  or  by  distension  of  the  bladder;  and  rest  even  in 
the  recumbent  position  has  no  effect  in  stopping  it.  After  the  haematuria 
has  existed  for  hours,  days,  or  weeks,  the  urine  may  suddenly  become 
quite  clear. 

Whilst  the  hanuaturia  lasts,  the  urine  is  not  equally  charged  with 
blood  at  each  micturition  ;  more  blood  is  passed  at  the  end  of  micturition 
than  at  any  other  period  of  its  flow :  the  quantity  is  often  exceedingly 
great,  and  the  loss,  even  from  a  small  innocent  growth,  may  be  fatal.  In 
cases  of  repeated  or  prolonged  haemorrhage  the  patient  becomes  anaemic 
and  waxen  looking,  and  the  lower  extremities  oedematous. 

Pain  is  not  a  constant  symptom ;  it  appears  late,  and  is  generally  due 
to  cystitis.  When  it  exists  it  is  often  very  intense,  and  is  worse  at  the 
end  of  micturition.    It  is  felt  in  the  hypogastrium  and  at  the  neck  of  the 


954  SYSTEM   OF  GYNECOLOGY 

bladder,  and  radiates  down  the  thighs.  But,  except  from  cystitis,  from 
nipping  of  the  growth  by  the  sphincter  vesicae,  or  from  retention  due  to 
clots  of  blood,  pain  occurs  only  Avhen  the  growth  is  pressing  upon  the 
nerves  as  it  infiltrates  the  bladder  wall. 

Physical  signs  are  those  ascertained  by  abdominal  or  vaginal  examina- 
tion, by  the  endoscope,  by  injecting  fluid  into  the  bladder  to  the  degree 
of  distension,  and  by  the  catheter.  If  these  means  afford  positive 
signs,  well  and  good ;  but  if  not,  we  must  not  exclude  tumour  from 
our  diagnosis,  if  the  above  described  functional  symptoms  be  present, 
especially  hematuria.  With  the  patient  lying  on  her  back,  with  her 
knees  and  shoulders  raised,  we  can,  in  a  thin  person,  sometimes  feel 
the  tumour  through  the  abdominal  walls  immediately  above  the  pubes. 
Still  more  frequently  can  it  be  felt  by  vaginal  examination,  especially 
if  at  the  same  time  the  bladder  be  firmly  pressed  upon  by  the  left  hand 
applied  on  the  hypogastrium.  The  result  of  this  kind  of  examination 
may  be  positive  or  negative.  It  may  be  negative  if  the  growth  be 
either  villous  polypus  or  fibro-papilloma,  or  a  small  pedunculated 
myxoma-fibroma ;  but  if  we  feel  an  irregular  nodular  or  infiltrated 
vesical  wall  or  thickened  mass  above  the  neck  of  the  bladder,  we  know 
the  disease  is  malignant.  Mucous  polypi,  when  large  and  abundant, 
have  also  been  felt  on  the  application  of  pressure  to  the  hypogastrium. 

It  is  well  always  to  examine  the  urine  first  passed  after  this  kind  of 
examination ;  for  when  tumour  is  present  the  examination  is  often 
followed  by  slight  haemorrhage. 

The  catheter  and  sound  ought  to  be  used  with  the  greatest  care ;  not 
only  as  to  their  aseptic  condition,  but  with  deftness  so  as  to  avoid 
bruising  the  tissue  of  the  tumour  and  provoking  haemorrhage. 

Diagnosis. — This  can  generally  be  made  pretty  accurately  (1)  by 
the  character  of  the  haemorrhage ;  (2)  by  the  physical  signs  described 
above ;  (3)  by  the  cystoscope  or  tube  which  in  certain  cases  enables  the 
new  growth  to  be  actually  inspected;  (4)  in  the  woman,  by  digital  ex- 
amination per  urethram,  which  affords  absolute  certainty  as  to  the 
presence  or  absence  of  growths,  even  the  smallest ;  and  this  should  be 
preferred  to  all  other  methods. 

If  a  tumour  of  some  weight  or  volume  be  detected,  or  a  general 
thickening  or  infiltration  of  the  base  of  the  bladder  exist,  we  conclude 
that  the  growth  is  malignant,  and  the  prognosis  very  serious. 

The  distension  of  the  bladder  with  a  solution  of  boric  acid  or  weak 
carbolic  solution,  if  it  excite  haemorrhage  as  the  last  drops  flow  away, 
is  a  valuable  diagnostic  guide  to  the  vesical  origin  of  haematuria. 
Sometimes,  especially  if  the  growth  be  near  the  neck  of  the  bladder, 
a  drop  or  two  of  blood  flows  through  the  injection  catheter,  either  as  it 
enters  the  vesical  cavity  or  as  soon  as  the  injecting  process  ceases. 

The  cystoscope  in  some  cases  gives  most  valuable  information;  but 
it  is  useless  in  cases  in  which  there  is  blood  in  the  bladder,  and  it  ought 
not  to  be  used  ui)on  all  jjatients  indiscriminately. 

The  chief   difliculty  in   most  cases   is   to   determine  whether   the 


DISEASES   OF   THE  FEMALE  BLADDER  AND    URETHRA       955 

hai'maturia  be  of  renal  or  vesical  origin.  This  may  be  decided  by  the 
presence  of  local  signs  in  the  renal  or  vesical  regions,  by  the  presence  of 
renal  or  ureteral  casts,  and  by  a  consideration  of  the  several  symptoms. 
The  difficulty  is  accentuated  when  both  regions,  or  neither,  yield  positive 
evidence.  We  must  then  have  recourse  to  distension  of  the  bladder,  or 
sounding ;  if  this  provoke  haemorrhage  we  have  proof  of  vesical  disease. 

From  the  haemorrhage  attending  acute  and  chronic  cystitis,  tuber- 
cular disease  of  the  bladder,  and  calculus,  the  diagnosis  will  be  readily 
made  by  a  careful  attention  to  the  history  of  the  case,  and  to  the  cardinal 
symptoms  of  the  respective  diseases. 

There  are  cases  of  haematuria  in  which  it  is  impossible  to  be  sure 
of  the  source  of  the  bleeding;  in  some  it  is  due  to  congestion  and  vari- 
cosity of  the  vessels  of  the  bladder. 

Prognosis.  —  This  is  always  serious.  The  malignant  growths  are 
unfavourable  for  removal,  as  they  infiltrate  the  vesical  walls  and  quickly 
recur.  The  benign  tumours  are  often  easily  removable;  but  some, 
especially  the  villous  polypi,  are  prone  to  come  again.  Then  there  is  the 
danger  from  haemorrhage,  Avhich  may  be  fatal ;  from  cs'stitis  running  on 
to  pyelo-nephritis,  or  from  intermittent  hydronephrosis.  These  causes 
of  death  arise  from  innocent  as  well  as  from  nlalignant  growths. 

As  to  the  duration  of  life,  Fere  gives  for  malignant  tumours  eighteen 
months  to  two  years.  Barling  three  years  ;  whereas  Guyon  has  operated 
upon  patients  for  epithelioma  in  cases  in  which  the  first  symptoms  of 
bladder  tumour  dated  back  ten  years  previously.  Such  cases  indicate 
either  that  cancer  progresses  much  more  slowly  in  the  bladder  than 
elsewhere,  or  that  tumours,  benign  at  first,  can  subsequently  become 
malignant.  We  know  this  to  be  the  case  in  uterine  myoma,  and  in 
tumours  of  other  kinds  in  other  parts  of  the  body. 

Vesical  malignant  growths  infect  other  parts  or  organs  but  slowl}-; 
death  is  by  no  means  invariably  due  to  secondary  invasions. 

The  benign  growths  may  go  on  for  years,  causing  only  occasional 
haemorrhage  at  longer  or  shorter  intervals,  and  of  greater  or  less  sever- 
ity. I  have  known  cases  go  on  for  ten  years  or  more ;  and  when  at  last 
an  operation  has  become  absolutely  necessary,  a  mass  of  villous  polypi 
enough  to  fill  a  breakfast  cup  has  been  removed. 

Tumours  of  the  bladder,  if  left  alone,  almost  alwaj-s  cause  death ; 
though  their  progress,  especially  in  the  benign  cases,  may  be  very  slow. 
It  is  mostly  by  haemorrhage  that  the  fatal  result  is  brought  about ;  in 
other  cases  by  pyelo-nephritis,  the  sequel  of  cystitis. 

Treatment.  —  The  best  palliative  means  are  incision  and  drainage 
of  the  bladder ;  the  only  curative  means  is,  of  course,  excision  of  the 
tumour. 

In  woman  the  best  incision  for  palliative  purposes  is  through  the 
vesico-vaginal  septum ;  sutures  should  xmite  the  vesical  with  the  vaginal 
mucous  membrane  over  the  edges  of  the  incision,  so  as  to  secure  a  per- 
manent opening. 

When  the  bladder  wall  is  not  largely  involved,  and  if  the  condition 


956  SYSTEM  OF  GYNECOLOGY 

of  ttie  kidneys  does  not  forbid,  the  curative  treatment  should  be  carried 
out  if  possible  ;  if,  however,  after  opening  the  bladder,  the  disease  is 
found  to  be  too  extensive  for  removal,  the  surgeon  must  fall  back  upon 
palliative' means. 

"When  a  growth  is  felt,  per  vaginam  or  with  the  sound,  to  involve  a 
large  surface  of  the  bladder  wall,  and  to  be  infiltrating  its  coat,  espe- 
cially in  the  neighbourhood  of  the  ureters  and  neck  of  the  bladder,  no 
operation  Avhatever  should  be  proposed  unless  the  haemorrhage  be  copious 
or  the  s^'mptoms  of  cystitis  severe ;  then  an  incision,  for  palliative  pur- 
poses only,  should  be  made.  This  should  be  the  vesico-vaginal  bouton- 
niere.  By  these  means  we  place  the  bladder  at  rest ;  thus,  by  drainage, 
we  remove  the  septic  urine  from  an  inflamed  bladder  ;  and,  by  prevent- 
ing the  alternation  of  distension  and  contraction  of  the  bladder  which 
is  the  chief  cause  of  the  bleeding,  we  check  the  haematuria.  When  the 
disorganised  state  of  the  kidneys  is  unfavourable  to  any  prolonged 
operation,  the  vaginal  drainage  is  still  indicated  to  check  haemorrhage, 
or  for  the  relief  of  the  sufferings  caused  by  cystitis. 

Urethral  dilatation  enables  many  tumou.rs  to  be  removed  easily  and 
thoroughly  through  the  canal ;  and  as  the  urethra  can  be  dilated  to 
between  two  and  three  centimetres  without  fear  of  after  ill  consequences, 
this  route  is  the  most  satisfactory  for  the  majority  of  cases  suitable  for 
curative  treatment.  Where  the  growth  is  too  large  to  be  removed 
through  the  female  urethra,  hypogastric  cystotomy  should  be  performed. 
It  must  suffice  here  to  say  that  the  methods  for  removing  the  growths 
are  by — (a)  tearing  them  away,  {U)  crushing  them  off  with  forceps  or 
ecraseur,  (c)  curetting,  (cZ)  cauterisation,  (e)  excision  with  the  bistoury 
and  closing  the  wound  in  the  mucous  membrane  by  sutures,  or  searing 
the  surface  with  the  cautery,  (/)  torsion. 

Tuffier  records  43  operations  through  the  urethra  without  a  death, 
and  5  suprapubic  oyjerations  all  successful. 

Stoxe  in  the  Bladder.  —  Vesical  calculus  is  rare  in  women,  because 
owing  to  the  shortness  and  dilatability  of  their  urethra,  calculi  which 
can  traverse  the  ureter  can  easily  escape  from  the  bladder.  Moreover 
gravel  and  gout  are  much  less  frequent  in  women  than  men. 

Local  causes  of  the  formation  of  stone  in  the  bladder  are  all  those 
which  tend  to  the  stagnation  of  urine  in  the  bladder  and  to  the  develop- 
ment of  cystitis.  When  these  two  conditions,  decomposition  of  urine 
and  cystitis,  occur  together,  as  so  often  they  do,  the  ammonia-magnesian 
phosphates  are  precipitated.  This  precipitation  may  occur  spontane- 
ously, and  thus  lead  to  the  formation  of  a  primary  vesical  calculus ;  or 
it  may  take  place  even  more  readily  around  a  concretion  which  has 
descended  from  the  kidney ;  and  this  is  the  process  by  which  uric-acid 
calculi  become  enveloped  in  a  white  casing  of  the  phosphates. 

It  is  V>y  this  same  precipitation  of  the  phosphates  that  foreign  bodies 
in  the  bladd(!r  become  encrusted  with  salts,  and  calculi  are  form(Ml  with 
such  things  as  bhjod-clots,  pieces  of  bone,  hairpins,  twigs  of  trees,  berries, 


DISEASES   OF   THE  FEMALE  BLADDER  AND    URETHRA       957 

and  SO  forth,  as  their  nuclei.  In  the  same  way,  too,  the  surface  of 
vesical  tumours  and  the  ends  of  catheters  retained  in  the  bladder  be- 
come encrusted  with  a  more  or  less  thick  white  layer. 

Chemical  Comjjosition.  —  There  are  three  chief  classes  of  vesical  cal- 
culi :  (i.)  The  most  frequent  are  formed  of  uric  acid  and  its  combina- 
tions ;  (ii.)  the  next  in  fi-equency  of  phosphoric  acid  in  combination  Avith 
volatile  alkali  and  the  alkaline  earths;  and  (iii.)  those  of  oxalate  of  lime. 

The  symptoms  are  pain,  frequency  of  micturition,  and  heemorrhage. 
To  these  may  be  added  —  (a)  the  sudden  interruption  of  the  stream  of 
urine,  a  symptom  to  which,  however,  undue  importance  is  often  given ; 
(6)  the  patient's  clinical  history,  especially  as  to  the  passage  of  gravel 
or  sand ;  and  (c)  the  previous  occurrence  of  an  attack  of  nephritic  colic, 
not  folloAved  by  the  discharge  of  a  calculus. 

Examination  per  vaginam  enables  us  to  feel  a  stone  or  stones,  and 
also  to  judge  as  to  their  number  and  size  ;  especially  when  firm  pressure 
is  made  on  the  bladder  above  the  pubes.  But  it  is  by  means  of  the 
sound  that  we  gain  the  more  precise  information. 

Prognosis.  —  The  supervention  of  septic  infection  of  the  bladder, 
whether  any  operation  have  been  done  or  not,  creates  the  danger  of 
calculus,  and,  as  ascending  suppurative  pyelo-nephritis,  conduces  to  the 
fatal  result.  The  existence  of  this  condition  before  the  operation  adds 
largely  to  the  risks  of  surgical  interference,  and  to  the  prevention  of  it 
is  attributable  the  mortality,  small  though  it  be,  which  follows  lithotrity 
as  now  practised  by  skilled  hands. 

The  spontaneous  expulsion  of  calculi  in  the  case  of  men  cannot  be 
reckoned  upon ;  but  women  pass  large  stones  through  the  urethra,  and 
others  still  larger  sometimes  escape  into  the  vagina  by  ulceration  of  the 
vesico-vaginal  septum. 

Treatment.  —  In  women,  owing  to  the  absence  of  the  prostate,  lithot- 
rity is  said  to  be  more  difficult  than  in  man ;  but  this  applies  only  to 
the  operation  in  hands  inexperienced  in  lithotrity  in  males.  Lithotrity 
is,  however,  rarely  required  in  women,  because  of  the  capacity  and 
dilatability  of  the  urethra.  In  women  with  stone  of  a  large  size  vaginal 
cystotomy,  followed  by  immediate  sutures,  is  an  easier,  safer,  and  more 
satisfactory  operation  than  the  hypogastric  operation.  In  female  chil- 
dren, the  best  operation  is  lithotrity  by  means  of  a  lithotrite  of  the  cali- 
bre of  a  full-sized  catheter  (jSTo.  12  or  14),  followed  by  the  evacuation 
of  the  fragments  with  Clover's  or  Bigelow's  evacuating  bottle  (aspi- 
rator) ;  and  in  adult  Avomen  the  same  operation  may  be  employed  for 
stones  which  are  too  large  to  be  safely  extracted  through  the  urethra  in 
their  entire  state.  Or  the  fragments  of  the  stone  may  be  removed  with 
forceps  through  the  dilated  urethra.  The  operation  is  allied  to  the 
mixed  operation  in  males. 

Henry  Morris. 


958  S VS TEM  OF  ■  G  YN^ COL OGY 


REFERENCES 

1.  American  Journal  of  Obstetrics. — 2.  Annales  des  maladies  des  organes  genito- 
nrinaires. — 3.  Archives  fur  Gynaecologic.  —  4.  Bavoux,  H.  Des  polypes  de  I'urethre 
chez  la  femme.  Strasbourg,  1844. — 5.  Brechot,  A.  Des  tumeurs  de  I'urethre  chez  la 
femnie.  Paris,  1876.  —  6.  Civiale.  Maladies  des  organes  genito-urinaires. — 7.  Dautin, 
E.  Du  diagnostic  de  quelques  eculements  urethraux  chez  la  femme.  Strasbourg, 
1869. —  8.  Dell' AcQUA,  P.  Historia  Phlegmhymen  proptoseos  urethrse.  Ticini  Regii, 
1830. — 9.  DoLLEz,  C.  A.  Des  polypes  de  I'urethre  chez  la  femme.  Paris,  1866.  — 10. 
DcpiN,  O.  P.  Sur  les  vegetations  he morrhoidales  de  I'urethre  chez  la  femme. 
Paris,  1873.  — 11.  Ehrhardt,  E.  Ueber  chronische  Ulcerationen  an  der  weiblichen 
Harnrohre.  Berlin,  1884.  — 12.  ^^tienne,  P.  De  I'urethre  de  la  femme,  etc.  Nancy, 
1880. —  13.  Fantorie  and  Mollinetti.  Phil.  Trans,  vol.  vii.  — 14.  Fissiaux,  E. 
Des  r^trecissements  de  I'urethre  chez  la  femme.  Paris,  1879.  — 15.  Fleyssac,  C.  E. 
De  quelques  tumeurs  de  I'urWwe  chez  la  femme  et  principalement  des  tumeurs  hemor- 
rhoidales.  Paris,  1879.  — 16.  Flotard,  D.  De  la  dilatation  de  canal  de  I'wethre 
chez  la  femme.  Montpellier,  1882.  — 17.  Gant.  Diseases  of  the  Bladder,  Prostate 
Gland,  and  Urethra.  London,  1884.  — 18.  Gottschalk,  S.  Ueber  die  weibliche 
Epispadie.  Wiirtzburg,  1883.  — 19.  Guebhard.  Etude  sur  la  cystite  tuberculeuse. 
Paris,  1878.  —  20.  Guyon,  J.  C.  F.  Ler;ons  cliniques  sur  les  affections  chirurgicales  de 
la  vessie  et  de  la  prostate.  Paris,  1888. — 21.  Hache.  Etude  clinique  sur  les  cystites. 
1884.  — 22.  Harrison,  R.  Ashurst's  Surgery,  vol.  vi.  1886. — 23.  Hartmann.  Des 
cystites  douloureuses  et  de  leur  traitement.  These,  1887. — 24.  Mauer,  Otto.  Ueber 
die  Exfoliation  der  Blasenschleimhavt.  Berlin,  1880. — 25.  Maurice,  V.  Histoire  de 
la  dilatation  rapide  de  I'urethre  chez  la  femme.  Nancy,  1877. — 26.  Morris,  H. 
Injuries  and  Diseases  of  the  Genital  and  Urinary  Organs.  London,  1895. — 27. 
MuNZNER,  M.  Ueber  Vorfall  der  Schleimhaut  der  weiblichen  Harnrohre,  Ehrlangen, 
1858. — 28.  NiTZE,  M.  Kystophotographischer  Atlas.  Wiesbaden,  1894.  —  29.  Notta. 
"  Observations  de  corps  etrangers  introduits  dans  la  vessie  et^  dans  le  canal  de 
I'urethre,"  Ann^e  m^d.  1877-8-9.  Caen.  —  30.  Nunez,  J.  E.  Etude  ,<iur  les  zrices 
de  conformation  de  I'urethre  chez  la  femme.  Paris,  1882.  —  31.  Picard,  H.  Traits 
des  maladies  de  la  vessie  et  des  V affections  calculeuses.  Paris,  1878.  —  32.  Piedpre- 
MiER,  F.  Contribution  a  I'^tude  des  maladies  de  I'urethre  chez  la  femnie  ;  urethroceles 
vaginales.  Paris,  1887.  —  33.  Reichelt,  P.  W.  Ueber  Prolaps  der  Uretralschleinihaut 
beim  Weibe.  Halle  a.  S.  1886.  —  34.  Silbermann,  O.  Die  briiske  Dilatation  der 
weiblichen  .Harnrohre.  Breslau,  1875. — 35.  Skene.  Diseases  of  the  Bladder  and 
Urethra  in  Women.  New  York,  1878.  —  36.  Soullier,  L.  Du  cancer  primitif  du 
m^at  urinaire  chez  la  femme.  Paris,  1889.  —  37.  Thompson,  Sir  H.  Tumours  of  the 
Bladder.  London,  1884.-38.  Tritschler,  E.  Ueber  der  Vorfall  der  Schleimhaut 
der  iveiblichen  Harnrohre  im  kindlichen  Alter.  Tiibingen,  1891.-39.  Tuffier. 
Appureil  urinaire.  Traits  de  chirurgie.  D upl ay  et  Rectus.  Paris,  1892.— 40.  Uebers- 
cHuss,  H.  Beitrdge  zu  der  Lehre  von  den  primfiren  Carcinomen  der  weiblichen  Urethra. 
Wurzburg,  1892.-41.  Voillemier,  A.  le  D.  Traitd  des  maladies  des  votes  iirinaires. 
Paris,  1881.-42.  Walsham.  Royal  Med.-Chir.  Soc.  11th  June  1895.-4:?.  West  and 
Duncan.  Diseases  of  Women.  London,  1879.— 44.  Winckel.  "Die  Krankheiten  der 
weiblichen  Harnnlhre  nnd  Blase,"  Billroth's  Handbuch.     Stutgard,  1877. 

Tumours  of  the  Urethra.  —  Henry,  A.  F.  Paris,  1858.  — Jondeau,  A.  Paris,  1888. 
—  Kkilmann,  H.  Wiirzburg,  1886.  —  Lemoine,  V.  Paris,  1866.  —  Menetrez,  A.  Paris, 
1874.  —  M(juTON,  E.  G.  Paris,  1876.  —  Thevenon,  L.  A.  Paris,  1879.  — Velten,  P.  F. 
Paris,  1862.  —  Weisgerber,  A.    Paris,  1877. 

H.  M. 


LIST   OF   AUTHORITIES 


Abel,  652,  694,  728,  732 

Ackermann,  605 

Adam,  G42 

Adami,  445 

Adams,  411 

Aetius,  22 

Agnew,  929,  930 

Aitkin,  535 

Alexander,  18,  411 

Allbutt,  7,  224,  249,  341 

Allingham,  263 

Amann,  420,  843 

Amussat,  604 

Anderson,  487 

Ausell,  563 

Apostoli,  13,  14,  28,  300,  305,  306,  307, 

316,  321,  322,  324,  325,  329,  333,  335, 

336,  597,  598 
Aran,  486,  554,  919 
Asch,  549 
Aslanian,  592 
Atlee,  10,  604 
Atthill,  209,  264,  265,  293 
Auteureich,  841 
Auvard,  295,  679,  687 
Aveling,  29,  341,  923,  924 

Baer,  621,  622,  623,  624,  628 

Baff,  891 

Baldy,  297,  298,  531 

Ballance,  269 

Ballantyne,  812 

Bandl,  4,  534,  535,  539,  546,  547, 552, 799 

Bantock,  12,  276,  584,  622 

Barbour,  8,  4,  23,  534,  535,  544,  771 

Bardenlianer,  621,  627 

Barling,  055 

Barlow,  534 

Barnes,  209,  250,  253,  277,  293,  472,  525, 

532,  533,  539,  915,  919,  920,  922 
Barrier,  920 
Barrow,  276 

Barth,  801,  805,  813,  816,  824 
Battey,  11,  601 
Baudry,  435 
Bayle,  562 
Bayliss,  342 
Beau,  de,  339 


Becqueril,  528 

Beidel,  384 

Beigel,  528 

Belfield,  952 

Bell,  8,  295,  873 

Benicke,  370 

Bennet,  5,  189,  190,  199,  211 

Bernard,  341 

Bernardet,  936 

Bernays,  586 

Bernhardt,  707 

Bernutz,  22,  23,  486,  525,  526,  527,  528, 

531,  532,  534,  535,  536,  540,  555 
Berry,  341 
Beyea,  794 
Bickersteth,  806,  807 
Bigelow,  957 
Billroth,  19 
Birschoff,  383 
Blanc,  447 
Blau,  697 
Blot,  67,  71 
Blundell,  639,  700 
Bodd,  342 
Boinet,  872 
Boldt,  592 
Bouchart,  340 
Bourdon,  22,  524 
Bozeman,  286,  477,  599,  773,  778 
Braithwaite,  281 
Brandt,  405,  522 

Braun,  209,  525,  546,  550,  557,  654 
Breisky,  384 
Brennecke,  192,  712 
Breslau,  525 
Breunicke,  622 
Broers,  443 
Brown,  230 
Brown,  Baker,  8,  603 
Browne,  921 
Bryan,  942 
BUcheler,  694 
Buck,  290 
Buckmaster,  94 
Budin,  285,  286 
Bumin,  207,  660 
Blirkle,  694 
Burns,  19 


959 


960 


SYSTEM  OF  GYNECOLOGY 


Biisch,  68 
Busey,  918 
Bvford,  624 
Byrne,  528 

Cabade,  341 

Cabot,  577 

Calvi,  22 

Campbell,  339,  340,  472 

Caradic,  91 

Cart,  798 

Carter,  465,  480 

Casati,  341 

Cavalliiii,  639 

Chaffev,  793,  794 

Chambers,  277,  278,  871 

Chambon,  873 

Championnifere,  809 

Champneys,  28,  29,  281,  362,  469 

Chapman,  257,  342 

Charcot,  224 

C  harrier,  594 

Chassaignac,  543 

(;heston,  472 

Chiari,  715 

Chiarleoni,  91 

Choux,  798 

Chrobak,  621,  624,  626,  627 

Church,  18 

Churchill,  22,  200,  263 

Civiale,  936 

Clark,  J.,  18 

Clark,  Sir  Charles,  18,  19 

Clay,  8,  10,  873 

Clover,  283,  631,  764,  919,  957 

Coblenz,  62,  805 

Coe,  800,  824,  825 

Cohnstein,  711,  713 

Collins,  289 

Colomiatti,  71 

Colucci,  293 

Conheim,  563 

Cook, 341 

Cooke,  476 

Cornil,  204,  205,  214,  215,  679,  822,  823 

Courty,  293,  925 

Coussat,  590 

Cramer,  102 

Crampton,  911,  914,  917 

Cr6d6,  525,  552,  912 

Cripps,  268 

Crosse,  912,  915 

Cruveilliier,  573,  585,  592,  841 

CuUen,  796,  799 

Cullin;,^worth,  24,  35,  534,  571,  590,  793, 

818,  819,  820 
Cusco,  274,  275 
Cutter,  325 
Czempin,  192,  346 

Darwin,  113 

Del^pine,  681 


Delaporte,  873 

Demons,  808,  809 

Denver,  van,  341 

Depage,  74,  75 

Dessaignes,  434 

Dezeimeris,  463,  464 

Diamant,  341 

Doderlein,  207,  385,  623 

Dodd,  342 

Doherty,  22 

Dolbeau,  535,  545 

Doleris,  286,  797,  805,  810,  811,  820,  876 

Doran,  12,  16,  25,  66,  85,  470,  471,  506, 
810,  811,  816,  840,  842,  845,  846,  848 

Doyen,  621,  628 

Dubois,  932 

Du  Chemin,  582 

Dudley,  623 

Duffin,  8 

Duhrssen,  57,  522,  724,  764,  765,  768 

Duke,  290,  295,  752,  754 

Duncan,  Matthews,  7,  22,  23,  25,  27,  98, 
195,  201,  232,  236,  263,  282,  374,  429, 
433,  435,  452,  485,  525,  528,  533,  543, 
544,  547,  557,  573,  606,  730,  852,  853, 
860,  913,  914,  920 

Duncan,  W.,  693 

Dupuytren,  899,  900,  932 

Durand,  96 

D wight,  92 

Dybowsky,  697 

Earl,  820 

Eastman,  621,  624,  626,  627 

Eberth,  804,  814,  816 

Edebohls,  627 

Edelmann,  304 

Edge,  522 

Edmunds,  209 

Eisenmann,  75 

Ellinger,  288,  364 

Embling,  341 

Emmet,  77,  189,  201,  218,  497,  533,  541, 
563,  600,  604,  677,  748,  756,  763,  765, 
766,  767,  768,  772,  774,  776,  919,  924 

Englemann,  27,  366 

Eve,  799 

Fabricius,  816 
Talk,  69 
Fantoni,  929 
Farre,  49,  389 
Fasbender,  370 
Fearn,  813,  818 
Fehling,  589 
F^nerley,  525,  533 
F6r6,  955 

FerguHson,  264,  266,  908 
Ferraresi,  70 
Fischol,  197,  198,  846 
Fitch,  877,  883 
Flaischlen,  846 


LIST   OF  AUTHORITIES 


961 


Flower,  44 

Fochier,  740 

Fordyce,  91 

Foriiiad,  825 

Fowler,  447 

Frankenhiiuser,  552 

Frank,  95 

Franklin,  476 

Freund,  42ti,  428,  430,  585,  700,  712,  761, 

850,  919 
Fritsch,  20,  209,  214,  215,  286,  290,  362, 

531,  599,  622,  692,  698,  705,  706,  714, 

722 
Frommel,  805 
Fuhrer,  846 
Furst,  73,  84,  731 

Galabin,  282,  476,  924 

Gallard,  531,  533 

Garceau,  519 

Gardner,  290 

Gariel,  919,  922 

Geddes,  113 

Gegenbauer,  114 

Gemmel,  583 

Gervis,  294 

Godart,  811 

Godlee,  825 

Godson,  282,  479,  638 

Goelet,  336 

Goffe,  623,  624 

Gonner,  207 

Gooch,  188,  211,  212 

Goodell,  229,  253,  282,  287,  288,  290 

Gosset,  17 

Gottschalk,  192,  202,  207,  735,  736,  738, 

837 
Gould,  30 

Goupil,  23,  525,  555 
Gu^rin,  534 
Gulland,  57 
Gurlt,  561 
Gusserow,   21,  557,  563,  589,   606,  650, 

656,  658,  679,  683,  697,  713,  715,  717, 

728 
Guyon,  570,  938,  949,  955 
Grandin,  88 
Gravel,  78 

Greenhalo-h,  292,  603 
Griffin,  274,  275 
Griffith,  478,  679,  851,  852,  865 

ITagepo-rn,  688,  748,  761,  885,  893 

Hall,  586 

Hamilton,  143 

Hardie,  573 

Harding,  341 

Harle,  340 

Harris,  340 

Hart,  4,  23,  465,  466,  467,  534,  544,  756, 

771,  806 
Hartniann,  694,  818 


Haultain,  72 

Hayes,  282 

Head,  45,  261,  866 

Hebra,  376,  382 

Heer,  590 

Hegar,  11,  13,  21,  180,  281,  282,  293,  318, 

364,  602,  622,  698,  752,  753,  758,  760, 

762,  769,  770,  771,  773,  866 
Heil,  84 

Heinricius,  204,  206,  299 
Hellin,  66 
Helme,  443 
Henke,  58 
Hennig,  805 
Henriet,  949 
Heoff,  von,  816,  817 
Heppaer,  101,  102 
Herber,  525 
Herman,  33,  478,  679 
Hernandez,  713 
Hertz,  566 
Herzfeld,  698,  699 
Hewitt,  6,  286,  544,  585 
Hicks,  26,  470,  471 
Higginson,  640,  904 
Hildebrandt,  597 
Hippocrates,  685 
Hirschfeld,  382,  575 
His,  45 

Hochenegg,  698 

Hodge,  6,  419,  420,  521,  599,  870 
Hofmeier,  200,  201,  622,  701,  714,  720, 

721,  731 
Hollander,  74,  75 
Homans,  68 

Huguier,  5,  528,  538,  557 
Hunter,  8,  873 
Hiiter,  72,  378 

Illich,  798 
Imlach,  537 
Immerwahr,  207 
Israel,  798 

Jackson,  359 

Jacobs,  519,  621,  628 

Jacquemier,  577 

.Tagoe,  341 

Jani,  794 

Janvrin,  825,  826 

Jeaffreson,  873 

Jessett,  295,  696,  874 

Jessop,  469 

Jobert,  779 

Jonas,  687 

Jones,  347 

Jones,  Dixon  (C),  825,  826 

Jones,  Dixon  (M.),  805,  843 

Jones,  M'Xaughton,  282 

Jones,  Sydney,  880,  881,  884,  889 

.lunkrr,  273 

Jusserand,  Nov6,  736,  737,  740 

3q 


962 


SYSTEM  OF  GYNECOLOGY 


Kahldex,  vox,  724 

Kaltenbach,  293,  622,  694,  712,  773,  804, 

813,  814,  816,  817 
Kammerer,  359 
Keating,  800 
Kehrer.  359 
Keiller,  487 
Keith,  10,  12,  14,  16,  342,  598,  616,  620, 

622,  626,  643,  873,  884,  885,  886,  889, 

892,  908 
Keith,  Skene,  480 
Kelly,  55,  432,  625,  894 
Kemarski,  917 
Kennedy,  384 
Keppler,  69 
Key,  642 
Kilian,  443 
King,  873 
Kiorisch,  5 
Kiwisch,  920 

Klebs,  73,  100,  101,  444,  564,  650, 843,  846 
Klein,  739 

Klob,  210,  445,  562,  592,  843,  846,  913 
Klotz,  198 
Kobelt,  70,  72 
Koch,  30 
Koeberle,  8,  10,  614,  620,  622,  628,  638, 

642 
Koiaczek,  841 
KoUiker,  443 
Konig,  4 

Kossmann,  69,  799,  805 
Kraske,  698 
Kroner,  919 
Krug,  627 

Krukenberg,  693,  713,  720,  946,  947 
Kuchenmeister,  291,  292,  365 
Kundrat,  27 
Kussmaul,  73 
Kustner,  191,  200,  204,  649,  921 

Lachapelle,  435 

Lacroix,  736,  737,  740 

Lallemand,  17 

Lamballe,  17 

Landau,  519,  652,  092,  694,  728,  732,  780, 

813,  817,  825,  826 
Landerer,  732,  733,  841,  842 
Lane,  877 
Langenbeck,  700 
Langhans,  736 
Langier,  525,  936 
Lantos,  209 
Lebert,  21 

Lee,  5,  189,  586,  592 
Lefort,  73,  89,  757,  759,  760 
Lefour,  593,  505 
Leiter,  257,  258 
Lambert,  899,  900 
Leopold,  27,  48,  472,  519,  589,  592,  590, 

034,  053,  818,  843 
Lepage,  434 


Lewers,  281,  488 

Lever,  22 

Lindsay,  105 

Lisfranc,  5,  586,  918 

Lister,  2,  10,  30,  622,  631,  873,  884 

Lockwood,  252 

Locock,  293 

Lohlein,  739 

Lucas,  342 

Luschka,  443 

Lusk,  346,  593 

Luther,  374 

M'Clintock,  525,  526,  547,  550,  563 

M'Dowell,  7,  8,  873 

Mackenrodt,  478,  692,  764,  765 

Madge,  525,  544,  547 

Mainert,  624 

Maisonneuve,  293 

Makins,  487 

Malassez,  846 

Malcolm,  252 

Malgaigne,  525 

Malherbe,  474 

Mallet,  583 

Mangiagalli,  79,  694,  695,  696,  720 

Marchand,  71,  736,  737,  843,  846 

Marckwald,  769,  770 

Marconnat,  389 

Marey,  564 

Martin,  12,  20,  57,  75,  76,  78,  79,  192,  292, 

384,  413,  438,  439,  472,  519,  621,  752, 

753,  760,  761,  762,  768,  771,  794,  795, 

806,  812,  821,  841,  909 
Martin,  C,  106 
May,  342 
Mayor,  443 

Meadows,  292,  525,  533,  556,  559 
Meredith,  858 
Merge,  207,  738,  794 
Meyer,  102 
Michaelis,  639 
Minot,  118,  126 
Mitchell,  Weir,  213,  228,  229 
Molitor,  342 
MoUinetti,  929 
Moostakov,  105 
Morand,  873 
More  Madden,  276,  290 
Morgagni,  49,  64,  72,  87 
Mott,  445 
Muller,  84,  342,  390,  593,  630,  656,  657, 

(558,  681 
Mund6,  209,  293 
Munster,  795 
Muret,  4(51 

Murray,  Milne,  305,  598,  600 
Museux,  919,  920 

Nagel,  60,  837 

N61aton,  293,  525,  520,  550,  557,  600,  880, 
881 


LIST   OF  AUTHORITIES 


963 


Netter,  798 

Neudorfer,  931 

Neugebauer,  203,  274,  437,  438,  779,  781 

Newiiham,  916 

Nikiforoff,  819 

Noble,  400 

Noggerath,  373.  919 

Nonat,  293,  528 

Nordau,  Max,  223 

Nuiin,  942 

OlSANDER,  936 

Olshauseii,  67,  203,  204,  207,  252,  293, 
525,  539,  606,  690,  712,  838,  840,  842, 
844,  845,  846,  864,  866 

Orthinann,  384,  794,  795,  812 

Ott,  de,  604 

Paget,  12,  21,  585,  934 

Palmer,  197,  210,  288,  289 

Paquelin,  266,  291,  609,  627,  705,  706, 

731,  762 
Par6,  17 
Paroua,  802 

Parry,  463,  464,  478,  479 
Pasteur,  30 
Paul,  22 

P^an, 106,  517,  518, 604, 621, 622, 692,  820 
Pearson,  290 
Peaslee,  282,  292 
Penrose,  84,  794 
Petit   929 

Pfannenstiel,  207,  714,  725,  726 
Pfluger,  66,  370 
Phillips,  105,  281,  282,  536 
Pick,  725,  726 
Picot,  656,  659 
Wayfair,  206,  263,  264,  285,  356,   541, 

551,  631 
Pogg,  525 
Poh-ier,  42,  43 
Pole,  79 

Polk,  3,  488,  625,  627,  634 
Poncet,  542,  545,  552 
Popoff,  72 
Porak,  276,  577 
Porritt,  377 

Porro,  595,  596,  634,  637,  712 
Porter,  825 
Pott,  932 
Pozzi,  34,  84,  97,  99,  101,  104,  191,  104, 

212,  292,  341,  345,  526,  534,  540,  557, 

559,  577,  593,  746,  779,  908,  909 
Preuschen,  v.,  390 
Priestley,  1,  210,  288,  289,  292,  370,  374, 

552 
Prochownik,  201,  218,  341,  420,  800 
Prost,  528 
Puech,  67,  90,  525,  534 

Quisling,  84 

Rainey,  240 


Rauschning,  92 

Keainier,  700 

Kecamier,  5,  21,  292,  293,  294,  524 

Recklinghausen,  v.,  806,  814,  816,  824 

Reeve,  914 

Regnier,  559 

Reid,  289,  290 

R6my,  84 

Renaud,  812 

Retzius,  51,  943 

Reverdin,  290 

Reymond,  309,  801 

Reynolds,  210,  552 

Rhein,  589 

Rheinstein,  813,  817 

Richard,  09 

Richelot,  519,  604, 621,  628,  633,  692,  694, 

695 
Rieux,  588 
Rindfleisch,  607,  846 
Ritchie,  802 
Rivington,  946 
Robert,  528,  548 
Robertson,  342 
Robin,  443 
Rokitansky,  21,  101,  210,  700,  803,  837, 

843,  846,  913 
Roser,  189 
Rouget,  525,  527 

Routh,  204, 295, 590, 591, 597, 747, 813, 816 
Routh,  C.  H.  F.,  281,  286,  293 
Routier,  559,  821,  822 
Roux,  17 
Rowlett,  342 
■Ruedinger,  37 
Ruge,  20,  79, 189, 196,  197, 198,  203,  204, 

205,  650,  651,  652,  679,  680,  731,  732 
Ruppolt,  69 
Ruysch,  525 


Saint-Hilaire,  73 

Sajous,  913 

Sale,  476 

Sanger,  73,  373,  374,  443,  595,  634, 
692,  712,  734,  735,  736,  801,  802, 
806,  812,  813,  814,  816,  817,  818, 
824,  825,  826 

Savage,  292,  599 

Scanzoni,  214,  293,  379,  525,  534, 
563,  812,  924 

Schaffer,  84,  375,  488 

Schatz,  432 

Schauta,  699 

Schleich,  272 

Schlesinger,  4 

Schmidt^  342,  731 

Schneevocht,  384 

Schramm,  786,  795 

Schroeder,  12,  13.  76,  201,  202,  210, 
293,  382,  534,  535,  538,  544,  563, 
584,  595,  (iOt),  622,  (')28,  651,  656, 
713,  720,  724,  771,  807,  812 


636, 
805, 
820, 


538, 


292, 
582, 
701, 


964 


SYSTEM  OF  GYNAECOLOGY 


Schuchardt,  391 

Schultz,  707 

Schultze,  199,  279,  420,  522,  841,  917,  918 

Schwartz,  800 

Segond,  517,  5-19 

Semon,  605,  607 

Senger,  814,  824,  825,  826 

Sequeira,  440 

Seyfert,  525 

Shattock,  818,  819,  844 

Sheild,  265 

Shucking,  763 

Siebold,  v.,  29 

Silcock,  793,  794 

Simon,  17,  298,  752,  753,  770,  773,  777, 
778,  779,  781 

Simpson,  A.  R.,  597,  769,  771,  850,  915 

Simpson,  Sir  J.  Y.,  5,  193,  200,  201,  211, 
216,  274,  276,  290,  292,  330,  348,  362, 
365,  384,  447,  449,  450,  525,  528,  530, 
544,  550,  552,  558,  559,  594,  600,  656, 
800,  920 

Sims,  Marion,  17,  55,  56,  262,  264,  274, 
277,  283,  288,  292,  293,  362,  364,  387, 
390,  599,  748,  753,  755,  757,  758,  761, 
763,  764,  765,  766,  767,  768,  769,  771, 
773,  774,  776,  777,  778,  779,  919,  920 

Sinclair,  12,  696 

Sin^y,  de,  82,  204,  205,  214,  215, 437,  846 

Sippe!,  68,  909 

Skene,  62,  68,  74,  75,  432,  577,  928 

Skoldberg,  201 

Sloan,  276 

Smart,  340 

Smith,  342 

Smith,  Albert,  420 

Smith,  Greig,  628,  633,  634,  712 

Smith,  Hey  wood,  282,  342 

Smith,  Tyler,  5,  8,  28,  29,  188,  189,  920, 
922 

Smyly,  820 

Sonnenburg,  931 

Sorel,  370 

Spaeth,  800 

Spamer,  310 

Spiegelberg,  199,  689,  594,  682,  725,  844, 
925 

Steffich,  844 

Stephenson,  3 

Stevenson,  480 

Stewart,  Sir  Grainger,  71,  798 

Stoltz,  550,  756,  761,  762 

Storer,  639 

Stratz,  585 

Strauch,  v.,  559 

Strong,  95 

Suppinger,  85 

Susserot,  563,  593 

Sutton,  Bland,  15,  16,  50,  62,  67,  70,  471, 
532,  562,  7H4,  793,  800,  804,  805,  806, 
810,  811,  8:'.9,  840,  841,  844,  846,  871 

Svcnsson,  913 


Tait,  Lawson,  11,  12,  14,  16,  68,  105, 
192,  252,  290,  328,  464,  471,  478,  479, 
527,  531,  557,  591,  601,  873,  877,  878, 
883,  889,  893 

Tardieu,  105,  535 

Tarnowsky,  374 

Tate   920 

Tayl'or,''462,  469,  522,  914 

Teale,  284 

Terrier,  694 

Theilhaber,  711,  712,  713 

Thiersch,  19,  653,  735 

Thiry,  922 

Thomas,  Gaillard,  23,  197,  201,  293,  295, 
420,  557,  917,920,  921,922 

Thompson,  Sir  Henry,  942 

Thomson,  113,  269 

Thornton,  Knowsley,  9,  11,  480,  532, 
622,  638,  678,  817,  841,  848,  880 

Tilt,  6,  525 

Tinns,  576 

Tourneaux,  96 

Trelat,  286 

Trendelenburg,  515,  874,  904,  906,  908, 
931 

Treub, 802 

Treves,  252,  498 

Trousseau,  293,  533,  536 

Tuckwell,  525,  538 

Tuffier,  818,  932,  934,  943,  947 

Turner,  585 

Tyson,  942 

Underhill,  605,  606 

Veit,  20,  21,  189,  196,  197,  203,  204,  374, 

387,  535,  650,  651,  652,  679,  680,  731, 

732,  817 
Velitz,  v.,  840 
Velpeau,  6,  17,  417,604 
Verneuil,  528,  809 
Viatto,  382 
Vidal,  780 
Vigues,  525,  531 
Virchow,  19,  21,  39,  366,  485,  525,  535, 

576,  591,  650,  724,  725,  826,  846 
Voelcker,  821,  822 
Voison,  525,  526,  527,  529,  531,  532,  533, 

534,  536,  537,  539,  540,  542,  545,  546, 

547,  549,  556 
Volkneaux,  294 
Vulliet,  274,  276,  707 

Wagner,  607,  656 

Waldeyer,  19,  49,  52,  60,  650,  653,  839, 

846 
Wallcnt,  341 
Walsham,  947 
Walter,  477,  805,  810 
Warnek,  810,  819 
Wathen,  290 
Watteville,  de,  33 


LIST   OF  AUTHORITIES 


965 


Watts,  920 

Webb,  765 

Weber,  256 

Weber,  F.,  552,592 

Webster,  Clarence,  464 

Weichselbaum,  786 

Weigert,  725 

Wells,  Sir  Spencer,  8,  9,  10,  91,  532,  616, 

637,  642,  656,  748,  749,  751,  758,  761, 

774,  799,  806,  807,  817,  873,  877,  878, 

879,  880,  881,  883,  884,889 
Wertheiin,  803,  865,  866 
West,  5, 189,  525,  536,  542,  544,  558,  563, 

936 
Westermark,  820 
Weston,  305 
White   29   922 
Williams, 'sir  John,  2,  7,  19,  20,  26,  27, 

361,  364,  444,  480,  552,  648,  652,  670, 

674,  678,  701,  702,  730, 731,  812 
Williams,  J.  D.,  66,  69,  70,  71,  72 
Williams,  Whitridce,  724,  788,  794,  795, 

799,  805,  839,  846,  865,  866 
Willius,  873 


Wilmont,  946 

Wilson,  342,  476 

Wiltshire,  28 

Winckel,  65,  66,  71,  206,  388,  534,  562, 

563,  593,  058,  660,  679,  083,  684,  699, 

729,  869 
Winter,  189,  207,  696,  697,  701,  702 
Winternitz,  780 
Woodhead,  Sims,  353 
Worrall,  477 
Wright,  256,  356 
Wyder,  27,  29,  203,  204,  205,  570 
Wylie,  366 
Wynter,  820,  821,  822 

Zedel,  821 
Zemann,  798 
Ziegler,  731 
Zinnis,  67 
Zuccarelli,  103 
Zuckerkandl,  698 
Zwanck,  408 

Zweifel,    559,    621,  627,   694,  804,   817, 
820 


INDEX 


Abdomen,  examination  of,  171 
Abdominal  tumour,  recognition  of,  854 
Abnormalities   causing    disease   of   the 

genital  organs  in  women,  112 
Accidental  and  operative  causes  of  dis- 
eases of  the  genital  organs  in  women, 
147 
Actinomycosis  of  the  Fallopian  tube,  798 
Acute  Intiammation  of  ovarian  tumours, 

849 
Adenoma  malignum,  729 
Adenoma  (simple)  of  uterus,  605 
Alexander-Adams  operation,  411 
Amenorrhoea,  27,  343  ;  primary  and  per- 
manent, 343  ;  secondary,  344  ;  symp- 
toms of,  347  ;  treatment  of,  347 
Anaesthesia  in  gyniBcology,  272 
Anatomy  of  the  female  pelvic  organs,  31 
Anatomy  of  female  pelvic  organs,  recent 

developments  in,  2 
Anteflexions  of  tlie  uterus,  see  Antror- 

sions  of  the  uterus. 
Anteversions  of  the  uterus,  see  Antror- 

sions  of  the  uterus 
Antiseptics  in  gynaecology,  267 
Antrorsions  of  the  uterus,  420  ;  causes 
and  complications  of,  421  ;  diagnosis 
of,  422  ;  symptoms  of,  421  ;  treatment 
of,  423 
Aphthous  vulvitis,  377 
Appendages,  uterine  removal  of,  904 
Armamentarium,  electrical,  300 
Ascent  of  the  uterus,  394 
Atrophy  and   hypertrophy  of   the   Fal- 
lopian tubes,  783 

Balneo-thkrapeutics  in  gynajcologj^ 
255 

Bladder,  anatomy  of,  37  ;  diseases  of, 
928;  cystitis  (acute),  936,  (chronic), 
940 ;  displacennMit  of,  928  ;  ectopian 
vesicfe,  930  ;  functional  diseases  of, 
932;  foreign  bodies  in.  949;  rupture 
of,  946  ;  stone  in,  956  ;  tubercular 
disease  of,  942  ;  tumoui-s  of,  951  ; 
vesico-vaginal  fistula,  948 


967 


Bloodletting  in  gynaecology,  265 

Broad  ligament,  cysts  of,  845 

Broad  ligaments,  malformations  of,  73 

Cesarean  section,  634 

Calculus  vesicae,  see  Stone  in  the  bladder, 
956 

Cancer  of  cervix,  070 

Cancer  of  genital  organs,  etiology  of,  133, 
643 

Cancer  of  the  Fallopian  tubes,  812  ; 
several  considerations  of,  823 ;  treat- 
ment of,  823 

Cancer  of  body  of  uterus,  713  ;  diagnosis 
of,  718  ;  etiology  of,  715  ;  pathological 
anatomy  of,  713;  prognosis  of,  720; 
symptoms  of,  715 ;  treatment  of,  721 

Cancer  of  the  ovary,  844 

Cancer  of  vagina,  391 

Carcinoma  uteri,  181,  643 

Catarrh  of  cervix,  see  Cervical  catarrh 

Cavernous  angioma  of  uterus,  591 

Cervical  catarrh,  195  ;  clinical  historj' 
and  symptoms  of,  195  ;  diagnosis  of, 
198  ;  pathology  in  relation  to  physical 
signs,  196,  treatment  of,  199 

Cervical  defornuties,  operation  for,  709 

Cervicitis,  etiology,  117 

Cervico-vaginal  fistula,  441 

Cervix,  circular  amputation  of  (Hegar), 
769  ;  fibromyoma  of,  582  ;  infravaginal 
hypertrophy  of,  763  ;  Marckwald's 
operation,  770;  Sims'  conoidal  incision, 
769 ;  lacerations  of,  426 ;  operation 
for  laceration  of,  765  ;  supravaginal 
amputation  of,  701  ;  supravaginal 
hypertrophy  of,  763 

Child-bearing,  iniiuence  of  fibromyoma 
on,  592 

Chronic  pelvic  cellulitis,  497 

Cirrhosis  of  the  ovary,  864 

Clitoris  and  labia,  malformations  of,  96 

Colpitis,  385 

Colpitis  mycotica,  388 

Colpoperineorrhaphy,  A.  Martiu's 
method,    761 


968 


SYSTEM  OF  GYNECOLOGY 


Colporrhaphy,  410,  757 

Colpotomy,  420,  522 

Complete  abdominal  hysterectomy,  626 

Complications  of  ovarian  tumour,  848 

Condyloma  of  vulva,  381 

Congenital  defects  of  development  as  a 

cause  of  disease  of  the  female  genital 

organs,  112 
Connective  tissue  of  pelvis,  anatomy  of, 

38 
Conservative  operations  on  the  ovaries 

and  tubes,  909 
Contagious  diseases  as  causes  of  disease 

of  the  genital  organs  in  women,  142 
Conthiuous  current,  mode  of  action,  315 
Curetting  of  uterus,  292,  355 
Current  regulator  in  electrical  treatment, 

303 
Cystic  corpora  lutea,  837 
Cystitis,  acute,  936  ;  chronic,  940 
Cystocele  (Stoltz  operation),  761 
Cystoma,  proliferating,  838 
Cysts  of  the  broad  ligaments,  845 
Cysts  of  the  Fallopian  tube,  801 

Deciduoma  malignura,  734  ;  course  and 
symptoms  of,  737  ;  diagnosis  of,  740  ; 
pathological  anatomy  of,  736  ;  prog- 
nosis of,  741 ;  treatment  of,  741 

Deciduoma  malignum  of  the  Fallopian 
tubes,  826 

Del^pine's,  Professor,  description  of 
methods  of  microscopical  examination 
of  uterine  tissues,  681 

Dermoid  growths,  ovariotomy  for,  894 

Dermoid  structures  in  ovarian  cysts,  840 

Dermoid  tumours  of  the  Fallopian  tube, 
802 

Dermoid  tumour  of  ovary,  etiology  of,  126 

Descent  of  the  uterus,  395  ;  causes  of, 
397  ;  complications  of,  401  ;  degrees 
of,  395  ;  pathological  anatomy  of,  396  ; 
Ijhysical  diagnosis  of,  402  ;  prognosis 
of,  404  ;  symptoms  of,  402  ;  treatment 
of,  404 

Diagnosis  of  chronic  inversion  of  the 
uterus,  915 

Diagnosis  in  gyiifecology,  151  ;  additional 
means  of  examination,  186  ;  examina- 
tion of  the  abdomen,  171  ;  examina- 
tion by  the  vagina,  177  ;  history  of 
the  patient,  151  ;  liistory  of  present 
illness,  160;  menstrual  history,  153; 
oljsletric  history,  158  ;  examination 
by  means  of  sound,  185;  previous  ill- 
nesses, 160 

Diet,  etiology  of  disease  resulting  from 
improper,  140 

Diffuse  pelvic  suppuration,  492 

Dilatation  of  tlio  uterus  in  gynaecology, 
276 

Dilatation,  I'apid,  of  uterus,  281 


Diphtheritic  vaginitis,  389 
Displacement  of  bladder,  928 
Displacements  of  the  uterus,  393 
Dysmenorrhoea,    28,    358 ;    etiology   of, 
117  ;  from  defective  development  and 
obstruction,  361  ;  intermenstrual,  369; 
membranous,  28,  366  ;  spasmodic  and 
inflammatory,  362  ;  and  sterility,  359  ; 
symptoms  of,  363  ;  treatment  of,  364  ; 
varieties  of,  360 

EcTOPiON  vesicae,  930 

Eczematous  vulvitis,  576 

Education  of  girls  at  and  about  the 
period  of  puberty,  220 

Education  of  girls,  etiology  of  disease 
resulting  from,  134 

Electrical  treatment  in  diseases  of 
women,  13,  300 

Electrical  treatment  of  fibromyoma,  14, 
324,  597 

Electricity,  mode  of  application  in  gynae- 
cology, 318  ;  therapeutic  application 
of,  317  ;  armamentarium  in,  300 

Elephantiasis  vidvae,  382 

Elytritis,  385 

Elytroperineorrhaphy,  vide  Colpoperi- 
neorrhaphy,  760 

Elytroplasty,  779 

Elytrorrhaphy,  420 

Elytrorrhaphy,  vide  Colporrhaphy,  757 

Emphysematous  vaginitis,  388 

Endometritis,  chronic,  203  ;  clinical 
history  and  symptoms  of,  203  ;  diag- 
nosis of,  203  ;  etiology  of,  122 ;  pa- 
thology of,  in  relation  to  physical 
signs,  204  ;  relation  of  micro-organ- 
isms to,  206  ;  treatment  of,  209  ;  treat- 
ment of,  by  electricity,  320 

Endometritis-villous,  352 

Episio-perineorrhaphy,  757 

Epispadias  in  woman,  95 

Epithelioma  portionis  vaginalis  uteri, 
646  ;  causes  of  death  from,  668  ;  diag- 
nosis of,  673  ;  duration  of  the  disease, 
(jQ'i) ;  etiology  of,  133,  655  ;  palliative 
operations  for,  703  ;  pathological  anat- 
omy of  epithelioma  of  uterus,  ()46  ; 
pregnancy  a  complication  of,  710; 
prognosis  of,  685 ;  recurrence  after 
operation,  696  ;  seat  of  origin  of 
growth,  (551  ;  symptoms  and  clinical 
course  of,  661  ;  treatment  of,  686 

Erysipelas  vulvae,  378 

Etiology  of  the  diseases  of  the  female 
genital  organs,  112 

Exfoliative  vaginitis,  389 

Extirpation  of  uterus,  operation  for, 
68(i  ;  Freund's  operation  for,  700; 
operations  for  partial,  701  ;  recurrence 
after  operation  for,  696  ;  results  of, 
093  ;  sacral  method  of,  698 


INDEX 


969 


Extraperitoneal  hfematocele,  530 
Extra-uterine  dysmenorrhcea,  .367 
Extra-uterine  gestation,  451,  see  Tubal 
pregnancy 

Fallopian  tubes,  anatomy  of,  48  ;  acti- 
nomycosis of,  798  ;  atrophy  and 
hypertrophy  of,  783  ;  calcuUis  simu- 
lating tumour  of,  799  ;  cancer  of,  812  ; 
cysts  of,  801  ;  deciduonia  nialignuin 
of,  82(5 ;  dermoid  tumours  of,  802  ; 
diseases  of  the,  782  ;  fibroma  and 
enchondroma  of,  798  ;  hydatid  disease 
of,  797  ;  inflammation  of,  784  ;  injuries 
of,  782  ;  lipoma  of,  802  ;  malformations 
of,  69  ;  myoma  of,  799  ;  papilloma  of, 
803  ;  sarcoma  of,  824  ;  tuberculosis  of, 
793 

Female  pelvic  organs,  anatomy  of,  31 

Fibrinous-polypus,  609 

Fibro-adenoma  of  uterus,  606 

Fibro-cystic  tumours,  586 

Fibroid  tumour  of  uterus,  see  Fibro- 
myoma 

Fibroid  of  vagina,  390  ;  vulva,  384 

Fibroma  and  enchondroma  of  the  Fallo- 
pian tube,  798 

Fibromyomaof  uterus,  561,  612  ;  absorp- 
tion and  atrophy  of,  587,  595  ;  calci- 
fication of,  585  ;  cervix  in,  582  ;  cystic 
changes  in,  586  ;  diagnosis  of,  574 ; 
diagnosis  of  subperitoneal,  578;  elec- 
trical treatment  of,  324,  597  ;  growth 
and  course  of,  57() ;  lifemorrhages 
from,  572  ;  htemorrhage,  source  of, 
572  ;  influence  of,  in  child-bearing, 
592  ;  influence  of  pregnancy  on,  592  ; 
influence  of  sterility,  564  ;  interstitial, 
580  ;  malignant  degeneration  of,  586  ; 
medical  treatment  of,  596  ;  pain  con- 
nected with,  575  ;  pathological  anat- 
omy of,  564 ;  pregnancy  connected 
with,  592;  pregnancy,  treatment  of, 
connected  with,  595  ;  secondary 
changes  in,  585  ;  sloughing  of,  586  ; 
submucous  variety  of,  576  ;  subperi- 
toneal, 575  ;  symptoms  of  subperito- 
neal, 577  ;  surgical  treatment  of,  599  ; 
symptoms  of,  573 

Fibrous-papilloma  of  uterus,  607 

FistuliB,  vaginal,  436 

Fistulous  openings,  operation  for  repair 
of,  771 

Flap-splitting  or  dedoublement,  775  ;  faj- 
cal  fistulse,  782 

Forceps  delivery  as  a  cause  of  laceration, 
426 

Foreign  bodies  in  the  bladder,  949 ; 
symptoms  of,  950  ;  treatment  of,  950 

Foreign  bodies  in  vagina,  391 

Freund's  operation  for  total  extirpation 
of  uterus,  700 


Functional  disease  of  the  bladder,  932 
Functional    disease   of    distant    organs 
(secondary)  in  gynaecology,  225 

Galvanometer  in  electrical  treatment, 

304 
Genital  organs  of  women,  development 

of,  27,  64  ;    etiology   of  diseases  of, 
112  ;   hypertemia  of,  372  ;    inflamma- 
tion of,  373  ;  malformations  of,  63 
Genital  organs,  external,  diseases  of,  372 
Gonorrhoea,  etiology  of  disease  resulting 

from,  143 
Grape-like  sarcoma  of  uterus,  725 
Gravid  uterus,  operations  on,  033 
Gynaecological   therapeutics,   249 ;    bal- 
neo-thcrapeutics  in,  255  ;  bloodletting 
in,  265  ;  drugs  in,  252  ;    general  hy- 
giene   in,    250 ;     local    therapeutical 
measures  in,  256  ;  operations  in  gynae- 
cology, 267  ;  rest  in,  251  ;  antiseptics 
in,  267 
Gynaecology,  development  of  modern,  1  ; 
anatomy,  2  ;   disorders  of  menstrua- 
tion,   27  ;     extra-uterine    pregnancy, 
14  ;  inversio  uteri,  29  ;  malignant  dis- 
eases,   19  ;    pathological    and   clinical 
aspects,  5  ;  pelvic  inflammations,  22  ; 
surgery  in,  7  ;  vesico-vaginal  fistulfe,  17 

H.EMATOCELE,  pclvic,  524 ;  causes  of, 
538  ;  definition  and  synonym  of,  524  ; 
diagnosis  of,  547  ;  extraperitoneal, 
530  ;  intraperitoneal,  529  ;  pathologi- 
cal anatomy  of,  536 ;  pathology  of, 
525 ;  prognosis  of,  551  ;  sources  of 
hfemorrhage,  581 ;  symptoms  and 
progress  of,  540  ;  treatment  of,  553 

Hsematoma,  see  Htematocele 

Hfematoma  of  the  ovary,  808 

Haematoma  vulvae,  381 

Haemorrhage,  from  fibro-myomata,  572 

Heredity  as  a  cause  of  disease  of  the 
female  genital  organs,  112 

Hermaphroditism,  100 

Hernia  of  ovary,  871  ;  symptoms  of,  871  ; 
diagnosis  of,  872 

Hernia  of  vulva,  379 

Herpes  vulvae,  376 

Hydatids  of  the  ovary,  841 

Hydatids,  etiology  of  disease  resulting 
from,  147 

Hydrops  folliculorum,  837 

Hymen,  the,  178;  anatomy  of,  34  ;  cause 
of  imperforate,  116  ;  maiformations  of, 
97 

Hypospadias  in  woman,  95 

Hysterectomy,  611  ;  after  treatment, 
639;  complete  abdominal  hysterec- 
tomy, 626  ;  for  fibromyoma,  12,  604  ; 
for  intractable  inversion.  633  ;  for  pro- 
cidentia, 630  ;  supravaginal  extraperi- 


97° 


SYSTEM  OF  GYNECOLOGY 


toneal,  614  ;  intraperitoneal,  618 ; 
Baer's  operation,  622 ;  Byford's  opera- 
tion, 624  ;  Dudley  and  Goffe's  opera- 
tion, 623 ;  Eastman  and  Chrobak's 
operation,  624 ;  Polk's  operation,  625 

Hystero-epilepsy,  oophorectomy  in,  230 

Hysteroma,  see  Fibi'omyoma 

Hysteropexy,  411,  763 

Idiopathic  hsemorrhage,  353 

Incarceration  of  ovarian  tumours  in  the 
pelvis,  851 

Incontinence  of  urine,  934 

Inflammation  of  the  Fallopian  tubes,  784 

Inflammation  of  the  ovaries,  861 

Inflammation  of  the  uterus,  187 

Injuries  to  bladder,  946 

Injuries  of  the  Fallopian  tubes,  782 

Insanity  in  relation  to  gynsecology,  229 

Intermenstrual  dysmenorrhoea,  369 

Interstitial  fibromyoma,  580 

Intraligamentous  tumours,  ovariotomy 
for,  895 

Intraperitoneal  hsematocele,  529 

Inversio  uteri,  29 

Inversion,  chronic,  of  the  uterus,  911  ; 
anatomy  and  pathology  of,  912  ;  course 
and  results  of,  917  ;  diagnosis  of,  915  ; 
etiology  of,  914  ;  mechanism  of  pro- 
duction, 913  ;  symptoms  of,  915  ;  treat- 
ment of,  918 

Inversion  of  uterus,  hysterectomy  for,  633 

Involution  of  uterus,  442 

KOLPO-HYSTERECTOJIY,  631 

Kolpokleisis,  779 
Kraurosis  vulvae,  584 

Labia  majora,  anatomy  of,  34 
Labia  minora,  anatomy  of,  34 
Laceration  of  cervix,  etiology  of,  119; 
immediate  repair  of,  426 ;  results  of, 
427 
Lacerations  of  pelvic  floor  proper,  746 
Laparotomy  in  pelvic  peritonitis,  514 
Lateral  deviations  of  the  uterus,  423 
Lefort's  operation,  759 
Leioma,  562 

Lipoma  of  tiie  Fallopian  tube,  802 
Local  therapeutical  measures  in  gynae- 
cology, 256 
Lupus  vulvie,  22,  382 
Jjymiiliatics  of  pelvis,  anatomy  of,  44 

Malignant  disease  of  uterus,  643 
Malignant  diseases  of  vulva,  383 
Malignant  growths  in  ovarian  cysts,  841 
Marriage,  etiology  of  disease  following, 

141 
Mechanism  of  production  of  chronic  in- 
version of  the  uterus,  913 


Membranous  dysmenorrhoea,  28,  366 

Menorrhagia  and  metrorrhagia,  349 ; 
during  active,  fertile  life,  351 ;  during 
menopause,  354  ;  during  puberty,  351  ; 
symptoms  of,  354  ;  treatment  of,  354  ; 
idiopathic,  353 

Menstruation,  disorders  of,  26,  339 ;  eti- 
ology of  disorders,  135  ;  its  relation  to 
the  education  of  girls,  221  ;  premature, 
339  ;  protracted,  343  ;  scanty,  348  ; 
vicarious,  347 

Mesometric  gestation,  463 

Metritis  and  endometritis,  acute,  202  ; 
chronic,  203 ;  clinical  history  and 
symptoms  of,  202  ;  diagnosis  of,  207  ; 
pathology  of,  in  relation  to  physical 
signs,  204  ;  treatment  of,  209 

Micro-organisms  in  the  etiology  of  disease 
of  the  female  genital  organs,  206 

Myoma  of  the  Fallopian  tube,  799 

Myoma  of  uterus,  etiology  of,  131 

Natural  progress  of  ovarian  tumours, 
847 

Nerves  of  pelvis,  anatomy  of,  44 

Nervous  system  in  relation  to  gynaecol- 
ogy, 220 

Neurasthenia  in  relation  to  gyuEecology, 
227 

Neuroses,  oophorectomy  and,  230 

Noma  pudendi,  377 

Nutrition,  defective,  in  gynaecology,  227 

Oophorectomy,  11,  904  ;  in  functional 
neuroses,  230  ;  in  inflamed  and  ad- 
herent appendages,  906;  for  fibro- 
myoma, 906 

Oophoritis,  862  ;  diagnosis  of,  808 ; 
symptoms  of,  866  ;  treatment  of,  808 

Oophoritis  serosa,  864  ;  tubercular,  865 

Operations  in  gynaecology,  267 

Operative  causes  of  disease  of  female 
genital  organs,  147 

Ovarian  artery,  anatomy  of,  49 

Ovarian  cystoma,  etiology  of,  127 

Ovarian  pregnancy,  471 

Ovarian  tumours,  836;  acute  inflamma- 
tion of,  849;  complications  of,  848; 
diagnosis  of,  852  ;  etiology  of,  845 ; 
incarceration  of,  in  the  pelvis,  851  ; 
natural  progress  of,  847  ;  pregnancy 
and  labour  complicated  by,  851  ; 
rupture  of,  851  ;  strangulation  of 
the  pedicle  in,  800 ;  torsion  of  the 
pedicle  in,  849 

Ovaries,  anatomy  of,  49  ;  carcinoma  of, 
844  ;  cirrhosis  of,  864  ;  hsematoma  of, 
868  ;  hernia  of,  871  ;  hydatids  of,  841  ; 
malformation  of,  65  ;  cedema  of,  864  ; 
prolapse  of,  8()9 ;  removal  of,  and 
menstruation,  346;  sarcoma  of,  843; 
tubercle  of,  865  ;  tumour  of,  836 


INDEX 


971 


Ovaries  and  tubes,  removal  of,  for  fibro- 
myoina,  628 

Ovariotomy,  7,  872  ;  accidents  and  com- 
plications in,  897  ;  adhesions  in,  888  ; 
after  treatment  in,  900  ;  arrangements 
for  operation,  876  ;  coverings  of  the 
patient  in,  875 ;  drainage  in,  892  ; 
dressings  in,  893  ;  emptying  and  de- 
livering cyst  in,  887  ;  history  of,  873  ; 
incomplete  operations,  897  ;  instru- 
ments used  in,  877  ;  irrigation  in,  891  ; 
operating  table  in,  874  ;  operating 
room  in,  874 ;  parietal  incision  in, 
886  ;  pedicle,  treatment  of,  in,  889 ; 
peritoneum,  toilet  of,  in,  891  ;  preg- 
nancy, ovariotomy  in,  896  ;  prepara- 
tion of  patient  for,  875  ;  preparatory 
measures  in,  873  ;  sponges  and  sponge- 
cloths  in,  87(i ;  suturing  the  parietal 
wound  in,  893 

Ovary,  solid  tumours  of,  ovariotomy  for, 
895 

Palliative  operations  for  cancer  of  the 
uterus,  703 

Papilloma  of  the  Fallopian  tube,  803 

Papilloma  of  genital  organs,  etiology  of, 
130 

Parametritis,  see  Pelvic  cellulitis 

Parovarian  cyst,  etiology  of,  127 

Parturition,  morbid  conditions  resulting 
from,  425 

Pelvic  abscess,  491 

Pelvic  cellulitis,  487  ;  anatomy  of,  48f  ; 
diagnosis  of,  493  ;  definition  of,  487  ; 
etiology  of,  88 ;  frequency  of,  489 ; 
pathological  anatomy  of,  489  ;  physi- 
cal signs  of,  490 ;  prognosis  of,  495 ; 
treatment  of,  490 ;  symptoms  of, 
489 

Pelvic  exudations,  treatment  of,  by  elec- 
tricity, 335 

Pelvic  floor,  anatomy  of,  744  ;  injuries 
of,  431 

Pelvic  inflammation,  22,  485 

Pelvic  organs,  anatomy  of,  31 ;  develop- 
ment of,  57 

Pelvic  peritonitis,  498;  definition  and 
nature,  498  ;  diagnosis  of,  509  ;  etiology 
of,  498  ;  pathological  anatomy  of,  503  ; 
physical  signs  of.  509  ;  prognosis  of, 
51 1  ;  symptoms  of,  606  ;  treatment  of, 
513 

Pelvis,  dissectional  anatomy  of,  53  ; 
structural  anatomy  of,  55 ;  surgical 
anatomy  of,  56 

Perimetritis,  see  Pelvic  peritonitis 

Perineorriiaphy,  Alexander  Duke's 
method,  754 ;  A.  Martin's  method, 
753  ;   Simon-llegar  operation,  752 

Perineum,  anatomy  of,  54  ;  rupture  of 
the,  433  ;    complete  rupture  of,  745  ; 


partial  rupture  of,  745  ;  plastic  opera- 
tion for  complete  rupture  of  (peri- 
neorrhaphy), 747 

Perioophoritis,  498,  861 

Perisalpingitis,  498 

Peritoneum,  anatomy  of  pelvic,  3,  50 

Peritonitis,  etiology  of,  144 

Peri-uterine  phlegmon,  see  Pelvic  cellu- 
litis 

Personal  habits  as  causes  of  disease  of 
the  genital  organs  in  woman,  135 

Phlegmonous  perivaginitis,  389 

Physical  exercise  in  relation  to  the  edu- 
cation of  girls,  321 

Placental  polypus,  609 

Plastic  gynaecological  operations,  743 

Plastic  operations  for  displacements  of 
pelvic  floor,  756 ;  for  pelvic  floor 
lacerations,  Emmet,  754 

Polypus  uteri,  557  ;  fibrinous,  609 ;  for- 
mation of,  570;  haemorrhage,  source 
of,  573;  intermittent.  571 ;  inversion 
of  uterus  from,  571,  915;  leucorrhcea 
connected  with,  573;  placental,  609; 
removal  of,  603  ;  sloughing  of,  571,  586 

Porro's  operation,  637 

Pregnancy  as  a  complication  of  cancer 
of  the  uterus,  710;  diagnosis  of,  173; 
influence  of,  on  fibromyoma,  592 ; 
ovariotomy  in,  896 

Premature  menstruation,  339 

Primary  and  permanent  amenorrhoea, 
343 

Procidentia  uteri,  395 

Procidentia,  hysterectomy  for,  630 

Prolapse  of  the  ovary,  869 

Prolapse  of  uterus,  395 

Prolapse  of  urethral  mucous  membrane, 
762 

Protracted  menstruation,  343 

Pruritus  vulvfe,  378 

Psammoma,  839 

Puberty,  menorrhagia  at  time  of,  351 

Purgatives  in  gyn;Tecology,  252 

Pyosalpinx,  505,  789 ;  etiology  of,  122 

Recto-vagixal  fistula,  442 

Rectum,  anatomy  of,  37 

Rest  cure,  the,  in  gynajcology,  228 

Rest  in  gjnuiecology,  251 

Retroflection,  see  Hetrorsion 

Retrorsions  of  the  uterus,  412  ;  causes  of, 

412;  complications  of,  414;  diagnosis 

of,  416;  prognosis  of,  417;  symptoms 

of,  414  ;  treatment  of,  417 
Retroversion  of  the  uterus,  see  Retror- 

sion  of  the  uterus 
Rheostats  in  electrical  treatment,  303 
Round  ligaments,  malformation  of,  73 
Rupture  of  the  bladder,  946 
Rupture  of  cystic  tumours  of  the  ovary, 

851 


972 


SyST£M   OF  GYNECOLOGY 


Sacral  method  of  total  extirijation  of 
uterus,  698 

Salpingitis,  784 

Salpiugo-oophorectomy,  904 

Sarcoma  botrj'Oides,  725 

Sarcoma  of  genital  organs,  etiology  of, 
133 

Sarcoma  of  the  Fallopian  tubes,  824 

Sarcoma  of  the  ovary,  843 

Sarcoma  of  uterus,  21,  722;  diagnosis 
of,  728 ;  pathological  anatomy  of,  728  ; 
prognosis  of,  728  ;  symptoms  and 
courses,  726  ;  treatment  of,  729 

Sarcoma  of  vagina,  391 

Secondary  amenorrhcea,  344 

Septic  vulvitis,  377 

Serous  perimetritis,  503 

Sexual  appetite,  causes  of  defective,  in 
women,  135 

Sexual  organs,  excessive  use  of,  as  a 
cause  of  disease  of  the  genital  organs 
in  women,  142 

Stenosis,  treatment  of,  by  electi'icity, 
317 

Sterility  and  dysmenorrhcea,  359 

Sterility,  231;  acquired  sterility,  235; 
contingent  sterility,  235  ;  acquired 
contingent  sterility,  238  ;  cases  of  ab- 
solute sterility,  233 ;  conditions  lead- 
ing to,  232 ;  influence  of  fibromyoma 
on,  563  ;   statistics  of,  232 

Stone  in  the  bladder,  956  ;  symptoms, 
prognosis,  treatment,  957 

Strangulation  of  the  pedicle  in  ovarian 
tumours,  860 

Subinvolution,  treatment  of,  by  electri- 
city, 323 

Submucous  fibromyoma,  567 

Subperitoneal  fibromyoma,  575 

Subperitoneo-pelvic  gestation,  463 

Superinvoliition  of  the  uterus,  447 

Supravaginal  extirpation  of  cervix,  701 

Supravaginal  hysterectomy,  intraperi- 
toneal, 618 

Supravaginal  hysterectomy,  extraperi- 
toneal, 614 

Surgical  anatomy  of  pelvis,  remarks  on, 
56 

Syphilis  as  a  cause  of  disease  of  the 
genital  organs  in  women,  142 

Tknts,  dilatation  of  uterus  by,  276 

Therapeutical  operations  in  gynsecology, 
274 

Thrombus  vulvae,  381 

Tiglit-lacing,  etiology  of  disease  from, 
136 

Tonics  in  gyn;ecology,  253 

Torsion  of  the  pedicle  of  ovarian  tu- 
mours, 849 

Tracliclorrliaphy,  765 

Tubal  abortion,  458 


Tubal  moles,  455 

Tubal  pregnancy,  451 ;  causes  of,  125, 
451  ;  changes  in  the  tube  in,  454  ; 
diagnosis  of,  472 ;  differential  diag- 
nosis of,  476  ;  the  placenta  and  decidua 
in,  464  ;  retention  of  the  foetus  in,  473 ; 
abortion  in,  459  ;  the  mole  in,  454  ; 
rupture  in,  460  ;  treatment  of,  481 

Tubercle  of  the  ovary,  865 

Tubercular  disease  of  the  bladder,  942  ; 
diagnosis  of,  944  ;  morbid  anatomy  of, 
943;  prognosis  of,  945  ;  treatment  of, 
945 

Tuberculosis,  etiology  of  disease  result- 
ing from,  146 

Tuberculosis  of  the  Fallopian  tubes,  793  ; 
pathology  of,  795  ;  symptoms  and  diag- 
nosis of,  796 ;  treatment  of,  797 

Tubo-uterine  gestation,  470 

Tumours  of  the  bladder,  951  ;  pathologi- 
cal complications  of,  953 ;  symptom 
of,  953  ;  diagnosis  of,  954  ;  prognosis 
of,  955  ;  treatment  of,  955 

Tumours  of  the  ovary,  836  ;  complica- 
tions of,  848  ;  diagnosis  of,  852  ;  etiol- 
ogy of,  845  ;  natural  progress  of,  847 

Tumours  of  the  uterus,  131,  561,  612 

Uretero-vaginal  fistula,  437,  780 

Ureters,  anatomy  of,  37 

Urethra,  anatomy  of,  36 ;  diseases  of, 
927 

Urethral  caruncle,  928 

Urethrocele,  762 

Urinary  fistula,  771 

Uterine  artery,  anatomy  of,  41 

Uterine  appendages,  removal  of,  in  fibro- 
myoma, 13,  601,  629 

Uterine  dysmenorrhcea,  301 

Uterus,  anatomy   of,  45 ;    adenoma  of, 
605 ;    antrorsions  of,  420  ;    ascent  of, 
394  ;   cancer  of  body  of,  713 ;   cancer 
of  the  cervix  of,  670  ;  and  epithelioma 
portionis   vaginalis   of,   646 ;    descent 
of,  395  ;  fibro-adenoma  of,  (i06  ;  fibro- 
myoma   of,    562,    see    Fibromyoma  ; 
fibrous  papil]o)na  of,  607  ;   inflamma- 
tion of,  187  ;  involution  of,  443  ;  lateral 
deviations  of,  423  ;  malignant  diseases 
of,  643 ;   malformations  of,  73 ;   mor- 
cellation  of,  in  pelvic  peritonitis,  517 
mucous  growths  of,  605  ;  partial  extir- 
pation of,    701  ;    reti'orsions   of,  412 
sarcoma  of,  722  ;    simple  growtiis  of 
561  ;  total  extirpation  of,  686  ;  ventro 
fixation  of,  420 

Vagina,  anatomy  of  the,  35  ;  diseases 
of,  385 ;  examination  by  the,  177  ; 
injuries  of,  resulting  from  parturition, 
427 ;  malformations  of,  86 ;  tumours 
of,  390 


INDEX 


973 


Vaginal  fistula,  430 

Vaginal  fixation,  763,  vide  Hysteropexy 
Vaginal    hysterectomy   in    pelvic    peri- 
tonitis, 517 
Vaginal  urethrocele,  762 
Vaginismus,  389 
Vaginitis,  385 
Varicocele  of  vulva,  381 
Vascular  growth  of  urethra,  928 
Veins  of  pelvis,  anatomy  of,  42 
Venereal  diseases  of  vulva,  379 
Venous  supply  of  uterus,  anatomy  of,  43 
Ventro-fixation  of  uterus,  411,  420 
Vesico-uterine  fistula,  779 
Vesico-utero-vaginal  fistula,  779 


Vesico-vaginal  fistula,  17,  430,  772,  948  ; 
etiology,  948 ;  symptoms,  948 ;  diag- 
nosis, 948  ;  treatment,  773 ;  Bozeman's 
method,  778 ;  Sims'  method,  773 ; 
Simon's  method,  777 

Vestibule,  34 

Vicarious  menstruation,  347 

Villous  endometritis,  352 

Vulva,  diseases  of,  373  ;  malformations 
of,  93  ;  pruritus  of,  378  ;  thrombus  of, 
381  ;  tumours  of,  383 

Vulvitis,  373 

"Weir  Mitchell"  treatment  in  gynae- 
cology, 228 


THE    END 


